OT assessments in hospital settings Flashcards
What is an assessment?
Information gathering process occupational therapists use to identify occupations and daily life activities that are problematic to people who seek OT services
What is the purpose of the OT assessment?
1) Understand occupations important to client’s life
2) Identify client’s occupational performance
3) Identify environmental factors impacting client’s occupations
4) Inform clinical reasoning about factors that facilitate/constrain OP for client
5) Inform collaborative goal setting and planning for intervention
6) Used later in OT process to monitor progress
Who is involved in an OT assessment?
- Assessment undertaken collaboratively by OT and client
- Variety of people contribute perspectives/understandings to assessment
When is the OT assessment carried out?
Acute setting: later in stay
Sub-acute and rehab: on admission
What to understand about a client’s OP before admission to hospital?
- Usual routines
- Areas of OP important in client’s life (valued occupations, responsibilities)
- Areas of OP which client experienced difficulty
- Strategies/supports which facilitated OP
What to understand about a client’s OP during hospital stay?
- How is client managing OP within hospital setting
- How consistent/variable has OP been in hospital
- Has client’s capacity or OP changed from before admission
- What have opportunities been for OP
- Factors might be limiting OP or underlying capacity
- What are client’s/carers expectations/concerns for OP on discharge
What to understand about a client’s OP after discharge from hospital?
- Where will client go after discharge
- Requirements for OP
- Environmental barriers to successful OP
- Resources available
- Experience after previous discharge
How does OT develop understanding of current and potential OP issues before admission to hospital?
-Initial interview
How does OT develop understanding of current and potential OP issues during hospital stay?
- Review of referral and medical record
- Initial interview
- Observation
- Information from team and others
- Additional assessment exploring areas of possible difficulty
How does OT develop understanding of current and potential OP issues after discharge from hospital?
Initial interview
What does the SMART goals acronym stand for?
S – specific M – measurable A – Achievable R – realistic T - timed
What should all documentation have?
- Date of service provision
- Client name and case number, signature
- Name of health professional, position,
- Date of recording
- Activities performed, patient responses
- Goals achieved
- Problems remaining
- Treatment plan modifications including discharge plans, evidence to support decision
