Visit Type
Treatment Note
Initial Evaluation
Re-Assessment
Modified Barium Swallow Study Report
Patient Progress Note
Patient Name:
*
Shawn "BJ" Johnson
Brayan Guitierriez-Torres
William Wiggins
Jarrell Walker
Brandon Olivares
Curtis Hutchinson
Other
Time out:
*
Time in:
*
Duration of Session:
*
Please Select
15 minutes
30 minutes
45 minutes
60 minutes
90 minutes
Treatment Date:
/
Month
/
Day
Year
Date Picker Icon
Type of Session:
*
Dysphagia Treatment
Cognitive Rehabilitation
Aphasia Treatment
AAC Training
Motor Speech Treatment
Oral-Motor Strengthening/ROM
Language Treatment
Articulation/Phonology Treatment
Other
Treatment Diagnosis
*
Primary Diagnosis
*
Subjective:
Insight:
Please Select
good
fair
poor
limited
Judgement:
Please Select
intact
limited
fair
Treatment Activities/Modalities
Patient completed graded therapeutic exercise(s) to target
Brayan's Goals & Objectives
Previous Progress
Current Progress
Brayan will use eye gaze as a means of engaging with an adult in motivating activity at least 5 times per session ind.
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Brayan will increase overall range of affect to express different emotions in play in 4/5 opportunities with minimal support
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Brayan will engage in age appropriate positive interactions to get attention from adults in 4/5 opportunities
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Brayan will sequence 2 step symbolic play ideas in 4/5 opportunities per session
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Brayan will identify actions/functions of objects/ pictures by pointing with 80% accuracy
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Brayan will imitate age appropriate phonemes in isolation/syllables and isolated words
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/p/
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/m/
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/t/
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Brayan will communicate basic information about self( with 100% accuracy):
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name
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age
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gender
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Curtis' Goals & Objectives
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Previous Progress
Current Progress
Goal 1: Curtis will articulate age appropriate phonemes in isolation/syllables/all word positions with 80% accuracy for 3 consecutive sessions.
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vowels: all
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p/b
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t/d
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k/g
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l/r
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"hard g"/"ch"
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"sh"
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/s/
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/w/
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1
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Goal 2: Given instruction, Curtis will increase comprehension of basic level language skills (describing concrete items, etc.) Given instruction, Curtis will utilize strategies to increase auditory processing skills (i.e. reauditorization, paraphrasing, requesting repetition / clarification, etc.) with increased independence and when provided with 1 - 3 therapist cues, in 7 out of 10 opportunities.
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Goal 3: Curtis will develop auditory processing of verbal material and direction following skills such that in order to function adequately in the classroom with decreasing amounts of assistance.
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Goal 4: Curtis will increase comprehension of "WH" questions (Who, What, When, Where, Why) within structured language activities, paragraphs, and short stories, with 1-3 therapist cues, in 7 out of 10 opportunities.
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4
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Goal 5: Curtis will retell verbally-presented material / directions, with 80% accuracy with limited assistance
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Goal 6: Curtis will strengthen speech sound discrimination skills, with increasing background noise, in 8 out of 10 opportunities, with decreasing teacher/therapist cueing.
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6
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Goal 7: To decrease distraction and increase on-task behaviors, Curtis will accurately and timely follow a classroom schedule, given a visual with 80% accuracy
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Brandon's Goals/Objectives:
*
Previous Progress
Current Progress
Goal 1: Brandon will utilize verbal approximation/sign language to indicate refusal and requests for items/activities desired (i.e. verbally approximate "yes" "no" or utilize sign for yes/no) in 9/10 opportunities for 3 consecutive sessions.
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Goal 2: Brandon will label age appropriate basic concepts utilizing verbal approximations or sign language after having been exposed to appropriate sign/word corresponding to item/thing in 9/10 opportunities for 5 consecutive sessions.
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a: animals
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b: numbers
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c: prepositions
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d: personal information(age/name/gender)
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e: clothing
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f: household items
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g: food
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i: request/question words (who/what/when/where)
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Goal 4: Brandon will model ST use of verbal expressions and/or signs 100% of opportunities for all sessions.
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Goal 5: Brandon will reduce use of gestures/non sign hand motions to indicate desires, using less than 10 per session.
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10
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Goal 6: Brandon will demonstrate comprehension of previously learned sign concepts/labels utilizing Total Communication Strategy, and review at onset of each treatment 100% of the time.
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Shawn "BJ"'s Goals/Objectives
*
Previous Progress
Current Progress
Modify Goal
Goal 1: BJ will increase his communication skills by requesting help and using pictures or words in order to have basic needs met 3 out of 5 opportunities
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11
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81-90%
95%
100%
Goal 2: BJ will be introduced to a functional communication system and utilize it to show his basic wants in 3/5 opportunities with verbal/visual cues.
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
12
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
Goal 3: BJ will follow 1-step verbal directions with less than 2 ST prompts/cues.
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
13
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
Goal 4: BJ will utilize visual with participation in routines on schedule with less than 5 challenging behaviors per session for 3 consecutive sessions.
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
14
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
Goal 5: BJ will appropriately verbalize/indicate emotional state when frustrated, upset, etc. by using a break card or verbalizing
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
95%
100%
Treatment Code(s)
Plan:
Recommend f/u with PCP
Add New Goals/Upgrade Current POC
Continue with ST POC
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