Note Treatment Note Name First Last DiagnosisF82 Specific development disorder of motor functionF84.0 Autistic DisorderF88.9 Other specified delays in developmentM62.81 Muscle weakness (generalized)R27.0 Ataxia, unspecifiedR27.8 Other lack of coordinationR27.9 Unspecified lack of coordinationR41.840 Attention and concentration deficitR41.842 Visuosptial deficitTime Start Hours : Minutes AM PM Time End Hours : Minutes AM PM 97110 Therapeutic Procedure (strength)97112 Neuromuscular Education97129 Therapeutic Education97150 Therapeutic procedure (group)97530 Therapeutic Activities97533 Sensory IntegrationEvaluation97165 Low Complexity97166 Moderate Complexity97167 High ComplexitySUBJECTIVEOBJECTIVESession 1: Demonstrated functional fine motor skills necessary to independently donn helmet snaps. Demonstrated functional static/dynamic balance needed to straddle bicycle. Demonstrated functional UE and LE coordination needed to walk and balance the bicycle. Basic propulsion was addressed (duck and giraffe walk). Visual-motor coordination exercises were practiced to educate the patient on fixation on external cues. By the end of today's session, the patient was able to circumnavigate approximately 20 yards with mod. assist. Session 2: The patient demonstrated functional UE and LE coordination needed to propel the bicycle with the use of pedals and external support from this therapist. Advanced propulsion was addressed (frog jump to pedaling). Visual-motor coordination was reinforced. By the end of today's session, the patient was able to circumnavigate >50 yards with CCG. Additionally, the patient was able to utilize visual-motor integration skills taught by this therapist to make turns and visually saccade between visual objects. Session 3: The patient demonstrated functional UE and LE coordination needed to propel the bicycle with the use of pedals and SBA from this therapist. Sequencing skills were addressed via the initiation of bicycle propulsion as well as coordination of LE/UE breaking to reduce fall risk. By the end of today's session, the patient was able to circumnavigate >100 yards independently.ASSESSMENTSession 1: The patient demonstrated decreased anxiety with riding a bicycle. Moreover, the patient is independent with donning a safety helmet as well as reducing the risk of falling. The patient/caregiver demonstrated a good understanding of the home exercise program provided by this therapist. Session 2: The patient demonstrated improved sequencing, bilateral coordination and gross motor skills necessary to propel the bicycle with reduced assistance from this therapist. The HEP was updated by this therapist; a good return of understanding was exemplified by the patient/caregiver. Session 3: The patient is independent with all skills necessary to ride a bicycle. All short-term goals have been met. Additional HEP modifications were made to address areas of function identified as long-term goals. PLANContinue current plan of care improving balance, coordination, gross motor, visual and sensory skills.Clinician Date of service MM slash DD slash YYYY Email to send report to:(Required) Signature
