Individualized Treatment Plan (ITP)

Patient Identifier:
Calculated Age:
Diagnosis:
Treatment Date:

KR 1a
2 y.o
Chronic lung disease

1/12/16

Goals for Todays Session:

1: Pt will demonstrate improved head control by demonstrating ability to visually track item vertically & horizontally while in seated
position 50% of the time.
2: Pt will demonstrate improved head control by demonstrating ability to maintain head in neutral position white in seated position
for 1 minute.
Activity Name &
Description
Supported seated
position (pt will be
passively placed in
seated position
while student
therapist provide
trunk to assist with
maintaining seated
position while pt is
in front of mirror to
elicit neutral head
positioning)

Duration
10 min.

Supported seated
10 min.
position 2 (pt will be
passively placed in
seated position and
will demonstrate
increase head
control by visually
tracking task object

Environmental
Set-Up
Mat
O2/HR
monitor
Blanket
Mirror

Mat
O2/HR
monitor
Blanket
Mirror
Toy

Skills Addressed

Grading Up

Grading Down

Occupation (all): needed to

perform all daily occupations and
especially play exploration.
Client factors: Vestibular, visual,
proprioceptive, joint stability,
muscle endurance
Motor performance skills:
stabilizes, aligns
Process performance skills:
attends

Pt is seated while
student therapist
provides assistance
through facilitation
of the hips while pt
performs neutral
head positioning.
This requires
increase proximal
stability in order to
maintain a neutral
head position.

Student therapist
will provide passive
assist by placing
palm against pts
forehead in order
for the patient to
maintain neutral
head position

Occupation (all): needed to

perform all daily occupations and
especially play exploration.
Client factors: Vestibular, visual,
proprioceptive, joint stability,
muscle endurance
Motor performance skills: moves,
stabilizes

Pt is seated while
student therapist
provides assistance
through facilitation
of the hips while pt
performs head
control through
visual tracking task

Pt will be passively
placed in seated
position and will
demonstrate
increase head
control by visually
tracking task object
in 1 plane.

vertically &
horizontally.)

Side lying position

(pt will be passively
placed in side lying
position and
demonstrate neck
extension)

Process performance skills:

attends

10 min.

Mat
O2/HR
monitor
Blanket
Mirror
Toy
Towel

Occupation (all): needed to

perform all daily occupations and
especially play exploration.
Client factors: Vestibular, visual,
proprioceptive, attention
Motor performance skills: moves,
stabilizes
Process performance skills:
attends

object vertically &

horizontally. This
requires increase
proximal stability in
order to maintain
head control while
visually tracking
item.
Pt will demo neck
extension in a
seated position
(against gravity)

Supine position (pt

will be passively
placed in supine
position with small
towel at neck to
elicit neck extension
to improve head
control): gravity
assisted position.

Preston, L. A. (2013). Evaluation of motor control. In H. McHugh Pendleton & W. Schultz-Krohn (Eds.). Pedrettis occupational
therapy: Practice skills for physical dysfunction (7th ed., pp. 461-488). St. Louise, MO.: Elsevier.
Case-Smith, J. (2010). Occupational therapy for children (6 th ed.). St. Louis, Missouri: Mosby/Elsevier.

Individualized Treatment Plan (ITP)

Patient Identifier:
Calculated Age:
Diagnosis:
Treatment Date:

LAD 17
3 y.o
Brain tumor with spinal mets

1/12/16

Goals for Todays Session:

1: Pt will complete Peabody assessment subtests of object manipulation, grasping, and visual motor integration to assess fine motor
and visual motor skills.
2:
Activity Name &
Description
Administer Peabody
assessment of
manipulation,
grasping, and VM
integration to
determine at what
level the pt. is in.

Duration
45 min.

Environmental
Set-Up
Mat
Peabody kit

Skills Addressed

Grading Up

Occupation (all): needed to

perform all daily occupations and
especially play exploration.
Client factors: attention,
perception, visual, vestibular,
proprioceptive, tactile, joint
mobility
Motor performance skills: aligns,
stabilizes, positions, reaches,
grips, manipulates, and
coordinates.
Process performance skills:
attends, chooses, uses, initiates,
searches.

Complete 6 subtests
of Peabody
assessment.

Grading Down
Complete 1 subtest
of Peabody
assessment.

Individualized Treatment Plan (ITP)

Patient Identifier:
Calculated Age:
Diagnosis:
Treatment Date:

AD 20a
18 y.o
Right femur ORIF and R iliac fracture

1/12/16

Goals for Todays Session:

1: Pt will improve ADL participation by demonstrating ability to perform bathing with SPV.
2: Pt will improve functional transfers by demonstrating ability to perform transfer from wc <-> shower bench with SPV.
3: Pt will improve ADL participation by demonstrating ability to perform LB dressing with SBA.
Activity Name &
Description
Functional transfer
(pt will transfer
from wc <-> shower
chair with SPV to
increase I with ADL
participation)

Bathing (pt will

perform bathing
with SPV to
improve I with ADL
participation)

Dressing (pt will

doff/don LB with
SPA to I ADL

Duration
5
minutes

20
minutes

10
minutes

Environmental
Set-Up
Pt in
wheelchair
Gloves
Shower bench
Gait belt

Gloves
Pt on shower
bench
Towels
Shampoo/soa
p

Gloves
Pt in
wheelchair

Skills Addressed

Grading Up

Grading Down

Occupation: ADL: functional

mobility
Client factor: Visual, vestibular,
proprioceptive, tactile, joint
stability, muscle power
Motor performance skills: aligns,
stabilizes, reaches, positions,
grips
Process performance skills: paces,
attends
Occupation: ADL: bathing
Client factor: Visual, vestibular,
proprioceptive, muscle power,
Motor performance skills: aligns,
stabilizes, reaches, positions,
grips, bends
Process performance skills: paces,
attends

Transfer using
FWW to shower
bench

Provide Min A for

transfer from w/c to
shower bench

Bathing while
sitting on shower
chair with no back
rest.

Bathing in shower
chair with armrests.

Occupation: ADL: dressing

Client factor: Visual, vestibular,
proprioceptive, muscle power,
joint stability

Dressing while in a
standing position.

Provide assistance
with LB dressing.

participation

UB & LB
clothing
Plastic for RLE
Surgical tape

Motor performance skills: aligns,

stabilizes, reaches, positions,
grips, manipulates, bends
Process performance skills: paces,
attends, chooses

Case-Smith, J. (2010). Occupational therapy for children (6 th ed.). St. Louis, Missouri: Mosby/Elsevier.
Bolding, D., Adler, C., Tipton-Burton, M., Verran, A., & Lillie, S. M. (2013). Mobility. In H.M., Pendleton, & W. Schultz-krohn (eds.), Pedrettis
occupational therapy: Practice skills for physical dysfunction. (7th ed. Pp. 233-294). St. Louis, MO: Elsevier.

Individualized Treatment Plan (ITP)

Patient Identifier:
Calculated Age:
Diagnosis:
Treatment Date:

KL 18b
1 y.o 4 mo
Lung Disease & 23 week premature

1/12/16

Goals for Todays Session:

1: Pt will demonstrate improve neck extension during prone position utilizing auditory and visual stimulus for 30 consecutive
seconds.
2: Pt will demonstrate improved visual and auditory tracking by demonstrating ability to track task object >50% of the time while in
supine position.
3: Pt will demonstrate improved play exploration by demonstrating ability to grasp task object when presented to hands 1/3 trials.
Activity Name &
Duration
Description
Tummy time (pt will 5
passively be placed
minutes
in prone position to
elicit neck extension
while using visual
and auditory
stimulus)

Environmental
Set-Up
Mat
Small toy

Skills Addressed

Grading Up

Grading Down

Occupation (all): needed to

perform all daily occupations and
especially play exploration.
Client factors: Vestibular, visual,
proprioceptive, muscle endurance
Motor performance skills:
stabilizes, aligns
Process performance skills:

Pt passively placed
in prone prop
position which
requires increase
proximal stability to
sustain position.

Pt will maintain
supine position with
rolled towel at neck
to elicit neck
extension in gravity
assisted plane.

Visual/auditory
tracking (pt will
demo ability to
visually &
auditorally track
task object through
various positioning)

Grasping (pt will

demo ability of play
exploration by
grasping task object
when it is presented
to hand)

10
minutes

Mat
Small toy

10
minutes

Mat
Small toy

attends
Occupation (all): needed to
perform all daily occupations and
especially play exploration.
Client factors: Vestibular, visual,
proprioceptive, control of
voluntary movement
Motor performance skills:
stabilizes, aligns
Process performance skills:
attends
Occupation (all): needed to
perform all daily occupations and
especially play exploration.
Client factors: Vestibular, visual,
proprioceptive, control of
voluntary movement, tactile,
muscle power
Motor performance skills: grips,
manipulates, reaches
Process performance skills:
attends

Pt visually tracks
Pt visually/auditory
item with 0 auditory tracks task object
stimulus provided
while maintaining
preferred supine
position.

Pt will reach and

grasp task object by
demonstrating
ability to provide
shoulder flexion to
grasp item.

Provide AAROM to
grasp task object.

Case-Smith, J. (2010). Occupational therapy for children (6th ed.). St. Louis, Missouri: Mosby/Elsevier.

Parham, L. D., and Mailloux, Z. (2010) Sensory Integration. (pages 325-372) in J. Case-Smith, Allen & J.C. OBriens Occupational
th
Therapy for Children 6 edition St. Louis, MO: Elsevier, Mosby, & Sanders Inc.