FINAL TEST Flashcards
(107 cards)
1
Q
WHAT IS THE TR ASSESSMENT REPORT/ SUMMARY
A
Summarizes information obtained during ASESSESMENT
Follow format laid out by AGENCY – there is not a consistent format used in all settings
Becomes part of individual’s OFFICAL CHART ; often shared with other members of the team
Culmination of all your assessment efforts; representsYOU, YOUR DEPARTMENT AND TR PROFESSION
2
Q
TRUE OR FALSE : ASSESSMENT REPORTS ARE PROFESSIONALLY WRITTEN?
A
TRUE :
Professionally written, using appropriate language; written in 3rd person
3
Q
TRUE OR FALSE : THE ASSESSMENT REPORT DOES NOT SUMMARIZE FACTUAL INFORMATION ?
A
FALSE
the assessment DOES Summarizes factual information; includes some additional interpretation and recommendations at end
4
Q
what should you avoid when writing an assessment report?
A
avoid to much TR “jargon”
5
Q
how is an assessment report typed?
A
single space-spaced; generally 2-3 pages maximum
6
Q
what should assessment reports always be?
A
professional and error-free
7
Q
what is the typical format of an assessment report?
A
Participant name Dates of the assessment Reason for referral (if applicable- in this case participant self referred) Background information Methods used to gather information Results of assessment Summary and interpretation Recommendations Signature(s) and date(s)
8
Q
what comes before the intervention plan?
A
assessment reports
9
Q
What is ecological assessment
A
assessing participants in their environment
10
Q
what are the two types of ecological assessments?
A
BROAD
FOCUSED
11
Q
what two questions does Broad ecological assessment involve ?
A
what do we know about the person ?
what do we know about their environment?
12
Q
what is some Information gathered that is geared towards what do we know about the person ?
A
strengths Physiological Emotional Social Cognitive Physical Spiritual
13
Q
what is some Information gathered that is geared towards the external strengths in what we need to know about their environment ?
A
Family Home World expectations Opportunities for inclusion Community resources Friends and acquaintances Community resources
14
Q
what is a focused ecological assessment?
A
Looks at the participants abilities in relation to the demands in which he or she will be included for recreation
15
Q
How do we bridge the gap between the participant and their environment to ensure successful participation?
A
Goals
Modifications
Supports
Strategies etc.
16
Q
What are the 5 focused ecological assessment steps?
A
Task analyze the preferred recreation activitity
Identify the abilities
Identify the gaps
Identify services, interventions and supports (that will bridge that gap)
Develop participates plan
17
Q
how many steps does the focused ecological assessment have?
A
5
18
Q
in comparison give 2 things about Broad Ecological Assessment
A
Participant and environmental strengths
Participant leisure experiences
19
Q
in comparison give 2 things about focused ecological assessment
A
focused on a specific goal
Bridging the gap so that participates can successfully participate
20
Q
what are the advantages of ecological assessment ?
A
Person centered- person in their environment
Allows greater understanding of participant and their concepts
Provides directions for supports and services
Strengths based and authentic
Uses multiple methods(interview, observation, recording tools, tests/questionnaires
21
Q
what are some disadvantages of ecological assessment ?
A
Time consuming
TR might have difficulty assessing participants in all environments
22
Q
what are some current stats of TR Assessments study conducted by Kemeny, Hutchinson and Cooke?
A
80.0 % of respondents reported completing individualized assessments for their clients
The most frequently used assessment tools were the TRAA , followed by the lesuire assessment inventory
23
Q
What some reason why the TR did not perform individualized client assessments?
A
Client shortened length of stay- _9%
Large caseloads per staff members- _18%
No agency requirement for a specific TR assessment- _31%
Only certain groups are assessed (by referral only)- __14%
Individualized assessment does not fit due to group focus- __22%
No assessment tool that suites the clientele- __6%
24
Q
what are the 10 Issues with assessment implementation
A
- Lack of an adequate number of T.R. assessments for the variety of T.R. settings and participants
- Lack of high quality assessments that accurately measure behaviours and attitudes important to T.R. practice.
- Lack of assessment resources about where / how to obtain tools
- Lack of financial resources to purchase appropriate tools
- Lack of practitioner expertise in electing, administering, scoring, and interpreting results
- failing to match assessment information gathered with appropriate placement in to programs / services.
- Failing to measure change using the same assessment instruments.
- Shortened length of intervention for participants
- Increased job duties, leaving less time for assessment.
- Lack of opportunities for updated training.
25
what are some challenges a TR practitioner can face during the assessment ?
Become as informed as possible about assessment
Look for formal professional development opportunities re: assessment
Observe / consult with peers in the field about what works for them
Engage in self reflective practice about your assessment processes. What could you be doing better?
26
what are narrative notes?
A form of progress note
Very few format and structure guidelines
Other staff must read entire note, can be time consuming
Therefore, knowing what to document is key!
27
what is the content of narrative notes?
Progress towards attainment of client goal
Regression from attainment of client goal
New patterns of behaviour
Consistency of behaviour
Verbal information provided by the client
Successful or unsuccessful attempts at a task
Appropriate or inappropriate interactions with staff, peers, visitors
Client responses to questions, instructions, requests
Initiative with actions, ideas, problem-solving, decision making
Follow-through or lack of follow-through with commitment
28
what is the frequency of process notes based on ?
Agency regulations and requirements (i.e. daily, weekly)
TR staff-time usage (documentation time should be scheduled into your daily routine)
Delivery of quality services (timely documentation helps to facilitate communication amongst staff members
29
what are the 10's of documentation ?
```
confidential
consecutive
contemporary
correct
centered on the participant
collaborative
complete
comprehensive
concise
clear
```
30
Narrate this :
George attended painting program but was not able to hold a regular paint brush due to arthritis
TR gave George an adaptive paint brush with a thicker handle and he was able to continue painting
On April 9th, George attended a painting program. George appeared to have a good time and was socializing with peers. During the program, George found it difficult to hold a regular paint brush due to his arthritis. The TR recognized George’s difficulties. The TR provided George with an adaptive paint brush with a thicker handle which allowed him to continue painting. George successfully completed his painting. For future recreation opportunities within the painting program, George will have his own adaptive paint brush
31
Narrate this:
On April 9th Betty was asked to join the TR and other residents for “coffee and news” where her and other residents would drink coffee and discuss the local daily news. Betty declined the invitations to the the outing. TR noticed that Betty had not been coming to all group programs lately. Betty is a woman that usually participates yet suffers from great depression. Betty has been staying in her room with lights of and curtains closed. TR has discussed Betty’s performance to charge nurse which will refer Betty to the doctor and have the Doctor look at Bettys behaviours. TR will continue to visit Betty daily and encourage Betty to participate in daily activities.
32
Implementation involves what?
Following through with the intervention plan by offering the programs outlined
Documenting information about the participant during the process
Regardless of your setting (healthcare/community based) documentation is critical to communication, collaboration, rigorous evaluation, and service improvement.
33
True or false; a common expression in documentation is: if its not in writing, it didn't happen
true
34
Documentation involves putting in writing the different elements of the therapeutic recreation process. What components are included?
```
Referral
Assessment Summary
Intervention Plan
Progress reports/notes
Incident reports
Plan updates
Discharge summaries
```
35
what does the acronym SOAP stand for?
Subjective- info from the client
objective- info based from tr
assessment- conclusions based on TR's professional opinion based on subjective and objective findings
plan- the measures taken to achieve a desired result
36
What are the 5 reasons why documentation in important?
Helps assure quality services
Facilitates collaboration with team and participant
Legal record
Ensures compliance with standards
Provides “PR for TR ” (Promoting what we are doing)
37
Frequency of documentation is determined by what?
Agency/departmental guidelines or requirements_
Staff time available
Opportunity for verbal communication between staff_
Occurrences which require documentation_
38
What are the 5 C's of documentation
Comprehensive
collaborative
centered on the participant
contemporary
consecutive
39
what are DARP notes?
Type of “focus charting”
Focuses on important elements of services (goals & objectives)
40
what are the benefits of DARP Notes
Ensures accountability
Enhances efficiency (avoid repetition)
Improves communication
41
what does the "D" stand for in DARP notes
D = Data (What the participant said; what behaviours or factual data you observe; your conclusions or interpretation
42
what does the "A" stand for in DARP notes?
A = Action (What you did)
43
What does the "R" stand for in DARP notes?
R = Response (How the participant responded to what you did)
44
what does the "P" stand for in DARP notes?
P = Plan (Based on interaction, what immediate steps you plan to take)
45
TRUE OR FALSE the discharge summary is usually the final form of documentation and evaluation ?
TRUE : The discharge summary is usually the final form of documentation and evaluation that a participant receives in an inpatient or outpatient facility.
46
what type of information should the TR include on discharge and referral summaries
client goals services received by the client
client responses to functional interventions, leisure education, and recreation participation
remaining concerns
recommendations including any follow up, referrals, community resources, or post discharge instructions
47
what question does the referral summary answer?
“how did we initiate services with the participant?”
48
what are referral summaries
In inpatient settings referrals will typically come from the physician.
In other settings (outpatient) referrals might come from different professionals family members and even from the participants themselves
49
what types of referral tests are there?
medical referral (healthcare based)
inclusion service referral (community based)
Recreation Service Self referral (healthcare or community based
50
what is a incident report?
Each agency will have a social form for documenting accidents, incidents, and unusual occurrences.
Documentation and analyses of incidents as a part of risk management is required by legislation
51
WHEN should we report an incident report?
```
Client death or injury
Broken equipment (lift)
Runaway client
Medication error
Child abduction
Patient fall
Patient abuse
```
52
WHAT do we report in a incident report?
```
When and where the incident occurred
Findings at the scene
Care of client (pre and post)
Client comments
Who was notified
PREVENTATIVE STEPS
```
53
what are the 6 guidelines fo documenting incident reports?
```
Write objectively- the facts
Include only essential information
Avoid opinions
Assign no blame
Avoid hearsay or assumptions
File the report properly
```
54
What are the documentation guidelines?
Know and follow agency requirements re: charting
format
Use simple terms, avoiding jargon and unnecessarily complicated words and phrases
Use appropriate, agency-accepted abbreviations
Describe, rather than interpret, using overt behavioural descriptions
Never falsify chart or tamper with a record
Be as precise as possible (e.g. “six times in one hour”, not “often”); avoid words such as “bad”; “good”; “average”; “better” that may mean different things to different readers
Avoid vague phrases such as “kind of”; “seems to be” etc.
Use correct grammar and spelling
Follow agency policies regarding electronic records
Write legibly, always in pen
Correct errors using agency format (generally a single line drawn through, “initials” written above or next to it, correction made, and initialed)
Never leave blank spaces or lines; don’t use ditto marks
Chart entries chronologically
Date and sign each entry, following agency protocol
Seek input from participant and team members when relevant
Ask yourself “would I be comfortable in having participant read this?”
Don’t delay charting, as important information may be forgotten!
55
What does the acronym AND stand for?
Allow natural death
56
what does the acronym c/o stand for?
complaints of
57
what does the acronym d/c stand for?
discharged
58
what does the acronym EDD stand for?
estimated date of discharge
59
what does the acronym HPI stand for?
History of presenting illness
60
what does the acronym a.c stand for?
before meals
61
what does the acronym hs stand for?
bedtime
62
what is the term :
Umbrella term used to describe activity or action-oriented services including recreation therapy/ occupational therapy; usually applied in psychiatric facilities
Action Therapy
63
what is the term:
Act of recording client assessments and interventions in the client’s chart. The chart is a permanent record that is considered a legal document and is audited to evaluate changes and quality of care
Documenting
64
what is the term :
The act of written documentation (often referred to as progress notes) on the clinical record or chart of a particular client
charting
65
what is the term to this definition ?
Intervention directed and structured by a recreation therapist to encourage clients to take action to restore their health
Prescriptive Activity
66
what is the term to this definition ?
| A person’s feelings, tone or mood; one’s emotional response
affect
67
what is the term to this definition ?
| Absence or near absence of any signs of affective expression
Flat
68
Uncontrollable impulse to perform an act repetitively
compulsion
69
Growth-oriented therapeutic approach developed by Carl Rogers. The role of the helper is to display unconditional positive regard for clients.
Person Centred Therapy
70
Condition characterized by purposeless, restless activity such as pacing. May serve to release nervous tension associated with stress, anxiety, or fear
Agitation
71
Activity that is dysfunctional or counterproductive in coping effectively with stress
Maladaptive behavior
72
Confused state of consciousness often characterized by delusions/hallucinations
Delirium
73
Taking into account the whole person interacting with the environment
Holistic
74
Inability to experience pleasure from activities that usually produce pleasure
Anhedonia
75
Confused as to time, place, and person (the position of the self in relation to other persons); characteristic of organic mental disorders
Disoriented
76
Weak or lacking normal tone or vigor
Atonic
77
Learning by watching the behavior of other persons; demonstration of a task, skill, or desirable behavior in order to teach another person
modeling
78
Unpleasant state of apprehension, tension or uneasiness from a vague or largely unknown or unrecognized source; characterized by increased heart rate, trembling, sweating, and disrupted breathing
Anxiety
79
Altered state of consciousness characterized by an exaggerated feeling of well-being, with or without foundation.
Euphoria
80
Spreading of a behavior within a group due to reducing restraints about performing the behavior after seeing others doing it
Contagion
81
Behavioral act with the goal of doing injury or harm to a person or object
Aggression
82
Charting done by members of the interdisciplinary team that indicates the progress, or lack thereof, being made by the client, patient, or resident
Progress Notes
83
People’s belief that they can succeed at something they want to do
Self Efficacy
84
Method of charting, which designates the four parts of each entry in a problem-oriented record: subjective data, objective data, assessment, and plan
SOAP
85
what does the acronym PRN stand for?
as needed
86
what does the acronym Q stand for?
every day
87
what does the acronym Q.H stand for?
every hour
88
what does the acronym BM stand for?
bowel movement
89
what does the acronym Dx stand for?
Diagnoses
90
what does # stand for?
fracture
91
what does the acronym f/u stand for
follow up
92
what does the acronym SOB stand for?
shortness of breath
93
what does the acronym BKA stand for?
BELOW KNEE AMPUTATION
94
what does the acronym AKA stand for?
ABOVE KNEE AMPUTATION
95
what does the acronym CA stand for?
CANCER
96
what does the acronym MI stand for?
MYOCARDIAL INFRACTION
97
what does the acronym TKR AND THR stand for?
TOTAL KNEE REPLACEMENT
| TOTAL HIP REPLACEMENT
98
what does the acronym O2 stand for?
OXYGEN
99
what does the acronym CVA stand for?
CEREBROVASCULAR ACCIDENT (STROKE)
100
what does the acronym ROM stand for?
RANGE OF MOTION
101
what does the acronym ADL stand for?
ACTIVITIES OF DAILY LIVING
102
what does the acronym W/C stand for?
WHEELCHAIR
103
what does the acronym RW stand for?
ROLLATOR WALKER
104
what does the acronym MCI stand for?
MILD COGNITIVE IMPAIRMENT
105
what does the acronym SMMSE stand for?
STANDARDIZED MINI MENTAL STATUS EXAM
106
what does the acronym MOCA stand for?
MONTREAL COGNITIVE ASSESSMENT
107
what does the acronym CDT stand for?
CLOCK DRAWING TEST
