Date: Monday, October 30, 2017 Resident: (removed for confidentiality)

S- OTA student arrived at rt’s room at 9:10am, rt was found awake, sitting in chair, watching her
television. Rt stated she was feeling “not so good, but the usual” and gave verbal consent to
engage in tx session. ---------------------------------------------------------------------------------------------------
O- OTA student brought a “worksheet fun page” with 11 lines on the page. Rt used right hand
to write with a sharpie marker. On line 1 rt wrote her name, rt was unsatisfied with her writing
and negative towards her self for her writing ability. OTA student continued to encourage and
motivate rt to continue. Rt traced the lines 2,3, and 4 in a straight line, rt’s right hand tremors
caused jerks in the line, but rt was able to complete the task. Rt then did zig zag lines from line
5 to 6 with difficulty. Rt completed the same task from line 6 to 7, 7 to 8, 8 to 9, and 9 to 10.
Rt’s lines improved when engaged in conversation, so that rt is not overthinking the task. On
line 11 rt wrote her name again to compare to line 1, there was significant improvement. At the
end of the tx session rt stated her “right hand felt worse, but wasn’t too bad”------------------------
A - Rt tolerated tx well and was engaged throughout entire tx session. Rt’s writing improved
while she was also engaged in conversation, and showed significant improvement from line 10
compared to line 5. Rt would benefit from continued writing activities working on both straight
and curved lines to work towards letters.-------------------------------------------------------------------------
P- Discuss tx session with OT, continue to work towards occupational goals. Next session to be
on Wednesday, November 1st.---------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------- Ashleigh Cole (OTA Student)
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