OTD 355 Final

subjective (S)

Client's perspective in their own words. Includes quotes about pain, goals, values, or limitations. Example: “I want to be more independent in bathing.”

objective (O)

Observable data collected by the therapist. Includes measurements, interventions, and client performance. Use clear, action-focused language: “Instructed in upper body dressing with mod A.”

assessment (A)

Clinical reasoning section. Interpret the data from the Objective and explain the implications. Discuss client’s progress, barriers, and rehab potential.

plan (P)

Clearly outline future interventions, frequency/duration of therapy, and planned goals. May include referrals or re-evaluation.

top-down approach

• Chart review

• Interview (occupational profile)

• Quick screening

• Functional performance assessment

• In-depth assessments as needed

PEOP (Person-Environment-Occupation-Performance)

Emphasizes the interrelationship between a person, their environment, and the tasks (occupations) they perform. Helps OTs examine how barriers in any area may impact participation.

MOHO (Model of Human Occupation)

Highlights the client’s motivation (volition), habits/routines (habituation), and performance capacity. It encourages understanding the person’s engagement in occupation.

occupational adaptation

 Focuses on improving the individual’s ability to adapt when faced with occupational challenges. It emphasizes client-centered outcomes and builds resilience through activity.

OT evaluations

• Chart review and team check-in

• Interview to understand the client’s background, values, and goals

• Observe performance and conduct screenings to guide full evaluation

• Adapt evaluation based on setting, culture, and discharge goals

role of OT

Leads the evaluation process, selects tools, interprets data, documents findings.

role of OTA

Assists with data collection under supervision, but cannot independently evaluate or interpret results.

validated assessments

COPM

OPH-II

PSFS

MoCA

SLUMS

WCPA

biVABA

Canadian Occupational Performance Measure (COPM)

A client-centered, semi-structured interview used to identify issues of personal importance to the client in the areas of self-care, productivity, and leisure. Clients rate the importance of each activity and score their current performance and satisfaction on a scale from 1–10. It is used for goal setting and measuring outcomes over time.

Occupational Performance History Interview II (OPH-II)

A comprehensive, semi-structured interview tool that explores the client's life history in the context of occupational participation. It focuses on occupational roles, daily routines, environmental influences, and personal meaning attached to occupation. Useful for building rapport, understanding long-term patterns, and informing intervention planning.

Patient-Specific Functional Scale (PSFS)

A client-centered outcome measure where clients identify 3–5 functional activities that are difficult due to their condition. Each activity is rated on a scale from 0 (unable to perform) to 10 (able to perform at prior level). It is sensitive to change and highly individualized, making it ideal for tracking progress over time in rehabilitation settings.

MoCA (Montreal Cognitive Assessment)

A brief cognitive screen evaluating memory, attention, language, visuospatial skills, and executive function. Scored out of 30.

Saint Louis University Mental Status Exam (SLUMS)

Another cognitive screening tool that assesses orientation, memory, attention, and executive functions; useful in detecting mild cognitive impairment and dementia.

Mini-mental state exam (MMSE)

Screens for cognitive function including orientation, recall, attention, calculation, and language. Scored out of 30.

WCPA (Weekly Calendar Planning Activity)

A dynamic assessment of executive functioning where clients plan appointments into a weekly calendar under specific rules. Evaluates problem-solving, inhibition, and working memory.

biVABA (brain injury visual assessment battery for adults)

Standardized battery to assess visual processing deficits post brain injury. Includes acuity, contrast, oculomotor function, visual field, and visual attention/scanning.

Motor-Free Visual Perception Test, 4th Edition (MVPT-4)

Evaluates visual perceptual skills (e.g., discrimination, spatial relationships, memory) without requiring motor output. Standardized for ages 4 to 80+.

COAST

Client, Occupation, Assist level, Specific condition, Time frame

Ex:  "Client will complete UB dressing with min A using adaptive equipment in 1 week."

quick screen tools and techniques

ROM (Range of Motion)

MMT (Manual Muscle Testing)

cognition screens such as MoCA (Montreal Cognitive Assessment) and SLUMS (Saint Louis University Mental Status Exam)

standardized pain scales (e.g., Numeric Rating Scale)

vision screening (acuity, visual field, tracking)

sensation testing (e.g., light touch, sharp/dull, proprioception)

A&O x4 (Alert and Oriented to person, place, time, and situation)

cueing hierarchy

Indirect verbal → direct verbal → gestural → tactile → physical assist

safety considerations for quick screens

Prioritize cognition, balance, vision, and strength screens for fall prevention and ADL safety

ADL evaluation client factors

• Cognition: Mental functions such as memory, attention, and problem-solving. For example, a client must remember steps for brushing teeth.

• ROM (Range of Motion): The movement available at a joint. Limited shoulder ROM can impact dressing.

• Strength: Muscle force generation. For instance, poor grip strength can affect utensil use during meals.

• Coordination: Smooth, controlled movement. Impacts buttoning, tying shoes, or using tools.

• Endurance: Ability to sustain activity. Clients with low endurance may need rest breaks during grooming.

• Balance: Stability during movement or stationary tasks. Crucial for safe bathing or reaching in the kitchen.

• Vision: Visual input guides safety and spatial awareness. Visual deficits might lead to neglecting parts of the body during dressing.

• Tone: Muscle resistance to passive stretch. High tone (spasticity) can limit mobility, affecting tasks like toilet transfers.

what ADLs should be prioritized in acute care?

grooming, hygiene

what ADLs should be prioritized in SNF?

bathing, toileting, dressing

what ADLs should be prioritized in home health?

meal prep, IADLs

grading tasks for ADLs

Modify environment, positioning, tools, and cues based on fatigue/cognition

levels of assistance

• Dependent: 0-25% performed

• Max A: 25-49%

• Mod A: 50-74%

• Min A: 75%+

• Supervision/Set-up: 100% with supervision

• Independent: 100% without help

cognitive-functional approach

• Evaluates real-life tasks (menu task, WCPA)

• Considers insight, initiation, safety, executive function

foundational skills

orientation, memory, attention

executive skills

problem-solving, planning, inhibition

O-log (orientation log)

A structured interview assessing orientation to person, place, time, and situation. Frequently used in TBI rehab to track daily cognitive recovery.

self-awareness of deficits interview (SADI)

Measures a client's insight into their cognitive and functional limitations. This is especially useful in OT when clients set unrealistic goals for ADLs or IADLs.

menu task

A functional assessment that requires clients to read and order from a menu, testing working memory and problem-solving. Useful in inpatient settings to assess safety and independence.

static assessments

One-time, standardized (MoCA)

dynamic assessments

Test-learning-retest approach (WCPA)

functional impact of sensory loss

Burns, injuries, ADL errors, poor coordination

sensory and perceptual evaluation patterns by diagnosis

Stroke (CNS): Contralateral loss

SCI: Below-level loss by dermatome

tools and techniques for sensation and perception

Light touch, stereognosis, proprioception, sharp/dull, ASIA scale

interpreting results of sensory and perceptual evals

Match sensory deficits to task impairments and tailor goals/interventions accordingly

what is the importance of a vision evaluation?

Vision affects safety, balance, and participation in all occupations

acuity

Clarity of vision, tested using eye charts or biVABA tools. In OT, impaired acuity may be identified during reading tasks or when a client has difficulty locating grooming supplies.

visual fields

The full horizontal and vertical range of what a person can see. Field cuts (e.g., homonymous hemianopsia) may be observed during mobility tasks or meal prep, when clients consistently miss items on one side.

oculomotor control

Eye movement abilities like tracking, saccades, and convergence. Deficits may appear when clients lose their place during reading or misjudge reaching distance.

visual attention/scanning

Ability to shift and maintain visual focus. Deficits can present as left neglect, often seen during dressing or drawing tasks in OT (e.g., only dressing one side).

visual perception

Higher-level processing including figure-ground, spatial relations, and visual memory. Evaluated using tools like biVABA and MVPT-4. For example, a client with spatial relation issues may misalign clothing fasteners or misplace items when setting the table.

left neglect needs

 train scanning strategies

hemianopsia needs

 use compensatory scanning or lighting strategies

what is the approach for medically complex evaluation?

Early mobility and occupation-based treatment, even in ICU

defer treatment for medically complex individuals if

FiO2 > 60%, SpO2 < 88%, HR < 40 or > 140, unstable vitals

evaluating safety includes

Know lines/tubes, collaborate with team, understand lab values and medications

common tools for medically complex evals

BMAT

RASS

CAM-ICU

SLUMS

NIHSS

BMAT (Bedside Mobility Assessment Tool)

A quick screening tool used to evaluate a patient's basic mobility functions such as sitting balance, standing, and stepping. Commonly used in acute care to determine safe discharge planning or need for therapy.

RASS (Richmond Agitation-Sedation Scale)

Assesses level of sedation or agitation in patients, especially in ICU. Scores range from -5 (unarousable) to +4 (combative). Therapists use it to determine if a patient is alert enough to participate in therapy.

CAM-ICU (Confusion Assessment Method for the ICU)

A tool to detect delirium in ICU patients who may be non-verbal. It assesses acute onset, inattention, disorganized thinking, and altered consciousness. Important for cognitive screening in medically complex cases.

NIHSS (National Institutes of Health Stroke Scale)

A standardized assessment to determine the severity of stroke. It evaluates consciousness, motor function, language, and visual fields. Helps determine prognosis and therapy direction.

special considerations for medically complex evals

• Post-Intensive Care Syndrome (PICS): persistent physical, cognitive, or psychological effects after ICU stay. OT supports early prevention and intervention.

• Functional goals often focus on low-level ADLs, safety with transfers, and balance while monitoring vitals.

scope of telehealth practice

Includes synchronous (real-time), asynchronous (recorded), and remote monitoring.

Used in home health, rural settings, or follow-up care.

ethical or legal considerations of telehealth

• Maintain HIPAA compliance, ensure informed consent, verify licensure across state lines.

• Client comfort with technology is essential

telehealth strategies and best practice

• Evaluate using top-down approach: chart review, interview, screens, functional eval.

• Adjust for setting: good lighting, camera angle, reliable tech.

• Use functional observation and coaching. Example: observe grooming via video call.

• Build rapport remotely, clarify instructions, and use family or caregiver support as needed.

what is the purpose of informal ADL assessments?

what you decide to evaluate changes based on setting and dx, PLOF

what is the purpose of a formal ADL assessment?

tying it to function

• PASS

• Katz Index of ADL

• Modified Barthel Index

• AMPAC

performance assessment of self-care skills (PASS)

Assesses 26 tasks; broken down by functional mobility, ADLs, IADLs-cognitive emphasis, and IADLs-physical emphasis 

• adolescents or adults with any dx

• identifies type and amt of assistance required

Katz Index of ADL

evaluates 6 activities: bathing, dressing, toileting, transferring, continence, feeding

Modified Barthel Index

assess a person’s functional independence in ADLs

activity measure for post acute care (AMPAC)

assesses the pt’s abilities to complete self-cares

formal IADL assessments

• Lawton IADL assessment

• Kohlman Evaluation of Living Skills (KELS)

• Executive Function Performance Test (EFPT)

Lawton IADL assessment

assessment of independent living skills at the present time

Kohlman Evaluation of Living Skills (KELS)

quick assessment of ability to perform IADL task

appropriate for anyone with cognitive deficits

performs 13 items in 5 areas: self-care, safety and health, money management, transportation and telephone, and work and leisure

executive function performance test (EFPT)

provides a performance-based standardized assessment to determine:

• which executive functions are impaired

• an individual’s capacity for independent functioning

• amount of assistance required

meta-cognition

self-monitoring, self-awareness, understanding and manipulating our own cognitive processes

executive function

working memory, inhibitor control, cognitive flexibility

foundational cognition

orientation, attention, long-term memory

assessments for Meta-Cognition

• Weekly Calendar Planning Activity

• Menu Task

assessments for executive functions

• trail making test (parts A and B)

• SLUMS

• MoCA

• Mini-Mental State Evaluation

• Short blessed test

• Medi-cog revis

• Allen-Cognitive Level Screen (leather lacing)

• Rowland Universal Dementia Assessment Scale (RUDAS)

Rowland Universal Dementia Assessment Scale (RUDAS)

culturally universal and designed for cognitive impairment and dementia screening  

• Assess memory, visuospatial orientation, praxis, visuoconstructional operations, judgement, and language  

• Scored out of 30 where < 22 indicates possible cognitive impairment  

• Use: mostly in the acute care, long-term, SNF, or inpatient rehab settings  

assessments for foundational cognition

• orientation log (O-log)

• COG-LOG

orientation log (O-log)

orientation, sustained attention, Episodic memory  

• 10 questions, scored from 3 to 0. 3 = correct spontaneously or upon first free recall attempt, 2 = correct upon logical cueing, 1 = correct upon multiple choice or phonemic cueing, 0 = incorrect despite cueing, inappropriate response, or unable to respond 

• Can use to test a patient’s orientation over time and if/how it has progresses 

• Use: mostly in the ICU, acute care settings d/t lower cognitive level required  

cognitive orientation log (COG-LOG)

orientation, sustained attention, short-term memory, spontaneous recall, motor praxis  

• 10 questions, scored from 3 to 0 depending on the task. Instructions are provided for each task on the back of the screen. Can use to test a patient’s orientation over time and if/how it has progresses  

• Use: mostly in ICU, acute care settings due to its lower cognitive level required  

dorsal column lesions

contralateral sensory deficits involving discriminatory touch, pressure, pain, proprioception, and kinesthesia; safety risk for skin breakdown due to ill-fitting orthotic device, challenges in completing ADL tasks that require vision occluded

lateral thalamic tract lesions

deficits in contralateral hemisensory loss for pain and temperature; safety risk for prolonged exposure to hot (burns) or cold (frostbite)

anterior spinothalamic tract lesions

deficits in contralateral hemisensory loss for light touch and crude touch; safety risk for dropping items/spilling; hard to gauge appropriate pressure to provide to object to maintain grasp

cuneocerebellar tract/rostral spinocerebellar tract lesions

deficits in ipsilateral UE and trunk proprioception; safety risk for falls when shifting weight while ambulating 

anterior cerebral artery lesions

contralateral LE sensory loss; safety risk for falls with ambulation, stairs, transfers

middle cerebral artery lesions

contralateral sensory loss of UE, LE, and facial regions; safety risk for consuming hot items and burning mouth/lips; hard to tell what is in your pocket 

lenticulostriate/thalamoperforate arterial lesions

contralateral sensory loss to 1 entire side of body; safety risk for falls d/t challenges with postural symmetry and coordinating movement

subcortical lesions

contralateral sensory loss involving face, UE, and LE; safety risk for injuries to these areas due to lack of awareness of noxious stimuli; fall risk

parietal lobe lesions

impaired sensory motor integration; safety risk to coordinate visual information with motor skills needed to respond appropriately; ex. Bumping into things

cortical lesions

impaired ability to interpret meaningful sensory information; safety risk for misidentifying objects by touch alone; risk of cuts

sensory testing techniques for primary somatosensory system

light touch

touch localization

pain

temperature

vibration

proprioception

secondary somatosensory system

two-point discrimination

Semme-Weinstein

graphesthesia

simultaneous stimulation

stereognosis

special sensory testing

visual functions

hearing functions

vestibular functions

taste functions

smell functions