OT 535: ADL Assessment & OT Documentation

The environmental and personal factors specific to each client that influence engagement and participation in occupations

Context

Engages client as a critical partner, ensures families are involved

Therapist

Critical voice in the decision-making process, acknowledged as experts in their own life

Client

2 primary steps in assessment

Screening, evaluation

Assessment step NOT used for diagnosis or treatment planning

Screening

Clinical reasoning: linear and rational; logical thinking about patient's problems

Procedural

Clinical reasoning: understanding the meaning of the disability in the patient's life

Narrative

Clinical reasoning: uses therapist's understanding of the unique patient, their specific condition, and life situation to predict what might happen and then make choices about the therapeutic plan based on this

Conditional

Clinical reasoning: therapeutic use of self; deciding how to approach the patient

Interactive

Clinical reasoning: logistics of delivering services within the organization

Pragmatic

Clinical reasoning: based on previous experiences with patients who seem similar

Generalization

Assessment consistently measures the behavior under study

Reliability

Assessment measures what it claims to measure

Validity

Test items represent the area being tested

Content validity

When interpreting an evaluation, OTs develop a "__________________" and identify strengths

Problem list

Problem lists do NOT include. . .

Diagnosis

Most direct method of assessing functional level or occupational performance

Occupational observation

ADL Assessment: uses self-report and direct observation to score patients (typically by multiples of 5)

Barthel Index

ADL Assessment: mandatory data collection tool for all SNFs serving Medicare clients; comprehensive tool that addresses many areas; results are used to place patients into Resource Utilization Groups

Minimum Data Set

ADL Assessment: Comprehensive tool developed for home health use; determines reimbursement rate by placing patients into Home Health Resource Groups (HHRGs)

OASIS

ADL Assessment: Evaluates occupational performance for 18 items using a 7-point scale

FIM

ADL Assessment: comprehensive assessment tool that is used to place patients into Case Mix Groups (CMGs)

IRF-PAI (GG Codes)

What will the person achieve by the time they are discharged? Related to functional skills and resumption of occupational roles

LTGs

Building blocks to achieve LTGs; address deficit

STGs

Brief note usually entered into the medical record to acknowledge that the referral order was received or a screening took place; reflect one session or one day's session

Contact Note

SOAP note: what the client said; client's status

Subjective

SOAP note: Observable and measurable; factual account of what occurred

Objective

SOAP note: your assessment of a client's response; interprets and authenticates the S & O

Assessment

SOAP note: plan for the next session; home program and follow-up

Plan