Occupational Therapy OT SOAP Note Example

S: Subjective

Chief Complaint (CC):
Mother states: “Jackson has difficulty holding a pencil properly, struggles with cutting with scissors, and avoids activities that require fine motor skills.”

History of Present Illness (HPI):

• Onset: Concerns noted since preschool, more pronounced in kindergarten.
• Duration: Persistent for the past 2 years.
• Character:
  • Difficulty with grip strength and finger coordination.
  • Tires quickly when writing or drawing.
  • Prefers gross motor activities over fine motor tasks.
• Impact on Function:
  • Avoids coloring, writing, and buttoning clothing.
  • Frustrated with schoolwork requiring fine motor skills.
• Previous Interventions:
  • None reported. Teacher suggested OT evaluation.

Medical History:

• Born full-term, no complications.
• No known medical conditions.
• No surgeries or hospitalizations.

Medications:

• None.

Allergies:

• No known drug allergies.

Family/Social History:

• Lives with parents and older sister.
• Attends first grade.
• No exposure to smoke.

Assessment

Diagnoses:

1. Primary Hypertension, Uncontrolled (ICD-10: I10)
   • Persistent elevation in BP (clinic: 158/94 mmHg, home logs: 150-160/90-100 mmHg) due to medication non-adherence (lisinopril 20 mg taken 3-4x/week), high sodium intake, and sedentary lifestyle.
2. Hypertensive Chronic Kidney Disease, Stage 2 (ICD-10: I12.9)
   • Evidence of renal end-organ damage: eGFR 68 mL/min/1.73m² (CKD Stage G2), elevated urine albumin/creatinine ratio (45 mg/g). Correlates with long-standing HTN and LVH on ECG.
3. Mixed Hyperlipidemia (ICD-10: E78.2)
   • Elevated LDL (130 mg/dL), low HDL (38 mg/dL), and triglycerides (200 mg/dL) despite statin therapy.
4. Obesity, Class I (ICD-10: E66.9)
   • BMI 32 with central adiposity; contributes to insulin resistance and HTN.

Differential Diagnoses:

• Secondary Hypertension (e.g., renal artery stenosis, primary hyperaldosteronism):
  • Less likely given chronicity of HTN, lack of hypokalemia (K+ 4.2), and identifiable non-adherence as primary cause.
• Obstructive Sleep Apnea (OSA):
  • Possible contributor to resistant HTN and fatigue; consider sleep study if fatigue persists despite BP control.

Comorbidities/Contributing Factors:

• Tobacco use (10 pack-years), poor dietary habits (high sodium), sedentary lifestyle, and medication non-adherence.

Plan

1. Hypertension Management:

• Pharmacotherapy:
  • Lisinopril: Increase to 40 mg daily (ACEi preferred for renal protection in CKD).
  • Hydrochlorothiazide (HCTZ): Add 12.5 mg daily (synergistic with ACEi; addresses pedal edema).
  • Adherence Strategy: Provide pill organizer; involve caregiver/spouse in medication reminders.
• Non-Pharmacologic Interventions:
  • Diet: Formal referral to renal/diabetic dietitian for DASH diet education (emphasize <1500 mg sodium/day, avoid canned/takeout foods).
  • Exercise: Prescribe structured aerobic exercise (30 min/day walking; use fitness tracker for accountability).

2. CKD Monitoring & Management:

• Repeat BMP in 4 weeks (monitor for ACEi-induced hyperkalemia or rising creatinine).
• Repeat urine albumin/creatinine ratio in 8 weeks to assess response to intensified HTN control.
• Avoid NSAIDs; counsel on nephrotoxin risks.

3. Hyperlipidemia:

• Continue atorvastatin 20 mg nightly; recheck lipid panel in 8 weeks.
• If LDL remains >100 mg/dL, increase atorvastatin to 40 mg nightly.

4. Obesity & Lifestyle Modification:

• Weight Loss Goal: 5% body weight reduction over 6 months (target: 199 lbs).
• Behavioral Counseling: Discuss SMART goals (e.g., 10,000 steps/day, meal prepping).

5. Tobacco Cessation:

• Prescribe nicotine patch 14 mg/day x 12 weeks.
• Refer to smoking cessation program (state quitline: 1-800-QUIT-NOW).

6. Follow-Up & Monitoring:

• Clinic Follow-Up: Return in 4 weeks for BP check, medication tolerance, and adherence review.
• Home BP Logs: Submit twice-daily readings (AM/PM) via patient portal weekly.
• Labs: Repeat BMP, lipids, and urine albumin in 4-8 weeks.

7. Contingency Planning:

• If BP remains >140/90 at next visit:
  • Add amlodipine 5 mg daily (CCB for additional BP control).
  • Consider screening for OSA with Epworth Sleepiness Scale + home sleep study.
• If eGFR drops below 60 or albuminuria worsens: Expedite nephrology referral.

8. Patient Education:

• Reinforce ACEi adherence (emphasize renal protection, even if asymptomatic).
• Warn about ACEi side effects: Dry cough, angioedema (seek ER for facial swelling), and dizziness.
• Provide written materials on low-sodium recipes and exercise routines.

ICD-10 Codes:

• I10 (Primary HTN), I12.9 (Hypertensive CKD), E78.2 (Mixed Hyperlipidemia), E66.9 (Obesity).

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Rationale:
This plan aligns with JNC 8 and KDIGO CKD guidelines, prioritizing RAS blockade, diuretic therapy, and aggressive lifestyle modification. By addressing adherence barriers, monitoring for end-organ damage, and setting incremental goals, the approach balances patient-centered care with evidence-based HTN management.

Subjective:

CC (Chief Complaint):
6-year-old Caucasian male referred for occupational therapy evaluation due to fine motor delays and difficulty with self-care tasks. Parents and teachers report concerns with handwriting, cutting with scissors, and buttoning clothing. The child avoids fine motor tasks, gets easily frustrated, and has difficulty sustaining attention during activities requiring dexterity.

HPI:

• The child has struggled with fine motor coordination since preschool.
• Difficulties are more noticeable now in kindergarten with increased academic demands.
• Struggles with pencil grasp, scissor use, and manipulation of small objects.
• Avoids coloring and writing activities and shows frustration when required to perform fine motor tasks.
• Reports occasional hand fatigue and cramping when writing for extended periods.

Substance Current Use:

• N/A

Medical History:

• Current Medications: None
• Allergies: No known drug allergies
• Reproductive Hx: N/A

ROS:

• GENERAL: No fevers, excessive fatigue, or recent weight changes
• HEENT: No vision or hearing concerns reported
• SKIN: No rashes or abnormal skin conditions
• CARDIOVASCULAR: No known heart conditions or palpitations
• RESPIRATORY: No history of asthma or breathing difficulties
• GASTROINTESTINAL: Normal appetite, no nausea, vomiting, or abdominal pain
• GENITOURINARY: No reported urinary concerns
• NEUROLOGICAL: No history of seizures, normal gait and coordination for gross motor skills
• MUSCULOSKELETAL: Reduced fine motor strength and dexterity; no joint pain or muscle weakness
• HEMATOLOGIC: No abnormal bruising or prolonged bleeding
• LYMPHATICS: No enlarged nodes reported
• ENDOCRINOLOGIC: No excessive thirst, urination, or other metabolic concerns

Objective

Diagnostic Results:

• No labs, X-rays, or other diagnostic tests are required at this time.

Occupational Therapy Observations & Standardized Assessments:

• Fine Motor Coordination:
  • Weak pincer grasp; uses immature fisted grip when writing
  • Poor control of writing utensils, inconsistent letter formation
  • Unable to cut along lines with scissors, difficulty stabilizing paper
• Hand Strength & Dexterity:
  • Struggles to manipulate small objects (buttons, zippers, beads)
  • Weak intrinsic hand muscles, fatigues quickly when performing fine motor tasks
• Visual-Motor Integration:
  • Below age-expected level on Beery VMI test
  • Difficulty copying shapes and letters from the board
• Sensory Processing:
  • Avoids activities that require messy play (playdough, finger painting)
  • Sensitive to certain textures in clothing and food
• Behavioral Observations:
  • Easily distracted, short attention span for fine motor activities
  • Becomes frustrated and avoids tasks perceived as difficult

Assessment

Diagnosis & ICD-10 Codes:

Primary Diagnosis:

🩺 F82 – Specific Developmental Disorder of Motor Function (Developmental Coordination Disorder – DCD)

• Rationale: The child exhibits fine motor coordination difficulties impacting handwriting, self-care, and academic tasks. No significant gross motor impairments are present, ruling out generalized motor disorders.

Differential Diagnoses & Rationale:

1. R27.8 – Other Lack of Coordination
   • Considered but ruled out because the child’s primary difficulties are fine motor-based, rather than generalized motor incoordination affecting ambulation or gross motor function.
2. F88 – Other Disorders of Psychological Development
   • Considered for a broader developmental issue but ruled out due to the specificity of fine motor deficits without global developmental delays.
3. F84.0 – Autism Spectrum Disorder (ASD)
   • Although some children with ASD exhibit fine motor delays, the child does not meet criteria for social communication deficits or repetitive behaviors characteristic of ASD.
4. F90.9 – Attention-Deficit Hyperactivity Disorder (ADHD), Unspecified Type
   • The child exhibits some distractibility and frustration with tasks but does not demonstrate pervasive inattention or hyperactivity across multiple environments. ADHD evaluation may be considered if symptoms persist.
5. Z72.820 – Sensory Processing Difficulties (Not Official ICD-10 Code but Commonly Used as a Descriptor)
   • The child demonstrates sensory avoidance behaviors, particularly with tactile input. Although sensory processing disorder (SPD) is not a formal ICD-10 diagnosis, it is a contributing factor to his difficulties.

Reflections

• The child demonstrates fine motor developmental delays, impacting handwriting, self-care, and academic performance.
• Sensory processing challenges may contribute to task avoidance and frustration.
• Occupational therapy will focus on strengthening fine motor coordination, improving sensory processing, and enhancing functional independence.

1. Occupational Therapy Goals:

Short-Term Goals (4-6 weeks):

• Improve pencil grip and sustain writing for 5 minutes without fatigue.
• Strengthen hand muscles to improve manipulation of small objects.
• Develop ability to use scissors to cut along lines independently.
• Increase tolerance for sensory experiences (messy play, textured materials).

Long-Term Goals (3-6 months):

• Achieve age-appropriate fine motor skills for writing, cutting, and dressing.
• Improve coordination for independent dressing (zippers, buttons).
• Increase engagement in fine motor tasks with reduced frustration.

2. Intervention Strategies:

Fine Motor Strength & Coordination:

• Hand exercises with therapy putty and stress balls
• Use of tweezers, clothespins, and small manipulatives
• Adaptive pencil grips and weighted writing utensils

Scissor Skills Training:

• Cutting along straight and curved lines with adapted scissors
• Progressing from basic shapes to more complex cutting tasks

Visual-Motor & Sensory Integration:

• Tracing and coloring activities to improve pencil control
• Multi-sensory writing activities (writing in sand, shaving cream)
• Exposure to various textures through structured play

Self-Care Skills:

• Practice dressing skills (zipping, buttoning, opening lunch containers)
• Encourage independence in daily routines

3. Parent & Teacher Education:

• Provide daily fine motor activities at home (Lego, coloring, puzzles).
• Encourage use of adaptive tools to reduce frustration.
• Implement a structured approach with short, engaging tasks.
• Gradual sensory exposure to improve tolerance for different textures.

4. Follow-Up & Progress Monitoring:

• Frequency: Weekly OT sessions (45 minutes).
• Reevaluation: 6-week progress check.
• Collaboration with teachers to implement classroom accommodations if needed.