Occupational Therapy SOAP Note

Occupational Therapy SOAP Note Name: John Doe DOB: 05/12/1985 Referral: Referred for occupational therapy due to difficulties with daily living tasks following a recent diagnosis of autism spectrum disorder. Initial Telephone Consultation: - Participants: John Doe, his mother, and the occupational therapist. Key points discussed included John's recent diagnosis and his challenges with daily tasks. - John is a 38-year-old male living with his parents. He has been diagnosed with autism spectrum disorder. - The local health authority has assessed John's needs, and an occupational therapy assessment is pending. - John expressed interest in occupational therapy to improve his independence and manage sensory sensitivities. - John reported difficulties with tasks such as dressing and cooking, and he experiences sensory overload in crowded environments. - John's living environment is supportive, but he struggles with noise sensitivity. - John uses noise-canceling headphones as a coping strategy and finds his bedroom a safe space. - John has social communication difficulties, impacting his ability to participate in community activities. - When overwhelmed, John may engage in self-injurious behaviors such as head-banging. - John has some self-awareness and is open to developing new skills based on past experiences. Recommendations: - Recommend a sensory profile assessment to understand John's sensory processing patterns. - The assessment will include observation of daily tasks and discussions about John's goals. - Recommendations will focus on strategies for independent living, such as task sequencing and environmental modifications. - Explore the use of weighted blankets to help manage sensory sensitivities. - Educate John on using visual schedules to promote self-regulation and understanding of sensory responses. - Identify local autism support groups, such as the Autism Society, and provide contact information. Next Steps: - John to discuss recommendations with his family and healthcare provider. - Instructions provided for John to book an occupational therapy assessment through the local clinic, contact: 555-1234. - Information on potential funding options for the assessment through local health services.