Treatment Presentation

By: Nicole Carver, Holly Pace, Amy Harter, Bethany Pergerson

Client: 45-year old male with recent diagnosis of ALS

**Impairment will not be addressed due to the progressively degenerative nature of the disease.

Goals:

1.) Activity: Effectively use compensatory strategy to tolerate Mr. Harter's

modified diet.

Participation: Mr. Harter will continue to enjoy meals with his family for

as long as possible.

Treatment: Demonstration of postural changes, such as the chin tuck, will

be modeled for Mr. Harter during the therapy session.

Time: 10 minutes

2.) Activity: Effectively use compensatory strategies to communicate with

familiar and unfamiliar listeners.

Participation:

A. Mr. Harter will contribute to the development of his augmentative

communication board.

B. Mr. Harter will use his augmentative communication board to

continue participation in his hobbies.

Treatment: The clinician will present a blank augmentative

communication board to Mr. Harter. Together, Mr. Harter and the

clinician will choose important activities to be displayed on the board. The

clinician will then model correct use of the communication board to Mr.

Harter and his family members.

Time: 30 minutes

3.) Activity: Effectively use his natural voice to continue communication with

familiar listeners, for as long as possible.

Participation: Continue to use his natural voice with family and friends, in

daily living activities.

Treatment: The clinician will encourage Mr. Harter to slow down during

speech, in efforts to increase intelligibility.

Time: 10 minutes

SOAP Note:

S: Mr. Harter was alert and rested prior to beginning tx today. O: Tx began with demonstration of postural changes. Mr. Harter performed the chin tuck, while swallowing orange juice and pudding. The clinician then modeled a reduced speech rate, which Mr. Harter imitated. The communication board was then introduced, and Mr. Harter indicated that he enjoyed horse races and golf. A: Mr. Harter successfully performed the chin tuck with 100% accuracy. He attempted to use reduced speech rate, and fatigued after 10 trials. This shows improvement from previous performance of fatigue after 5 trials. Mr. Harter was motivated to participate in the development and use of his communication board. Mr. Harter exhibits spastic characteristics in his daily functioning, as a result of ALS. P: Continue treatment of the previously determined goals.