client assessment exam 2

types of assessments

non-standardized, standardized, signs, scales

non-standardized assessment

can be tailored to fit needs of facility

non-standardized assessment 5 components

1. nominal data- don’t measure anything, allow for placement in group.

2. attitudinal data- way of thinking, feeling, acting

3. functional data- info RT can observe or measure

4. summary of findings- using clinical opinion

5. proposed TX direction- TX plan

standardized assessment

tested for reliability and validity

RAI stands for

rapid assessment instrument

RAI is

standardized, used to further assess or monitor during sessions

difference b/t non-standardized and standardized

non-standardized has more freedom to find info. standardized is tracking data

standardized assessments come from

red book

rehabilitation measures database

free online resource

administering assessments step 1

set up environment, greeting, build rapport

setting up interview situation

before- be prepared with questions, during- focus on client and answers, closing- signal times up and summarize, tell client what’s next

administering assessments step 2

obtain background info

administering assessments step 3

ask open-ended questions and play, leisure, recreation, community, life.

frequency/time, setting, casual/serious, core/balance, alone/with others, barriers/facilitators, motivators/meaning, satisfaction, integration, level of participation

administering assessments step 4

look at perceptions- QOL, health, social relationships, psychological health, living environment, self-perception, happiness in life

administering assessments step 5

can you incorporate family

administering assessments step 6

conduct functional assessment

administering assessments step 7

determine areas of concern

administering assessments step 8

determine goals and objectives

free time boredom scale 4 components

1. meaningfulness- cl. has focus or purpose during free time

2. mental involvement- cl. has enough to think about and finds thoughts satisfying

3. speed of time- cl. has enough time

4. physical involvement- cl. has enough physical movement to satisfy them

clinical interviewing- interviewer techniques

build rapport first, probe, summarize, clarification, confrontation

motivational interviewing

person centered

motivational interviewing- OARS

open questions, affirmations (recognize cl. strengths and acknowledge positive behavior), reflective listening (active listening and share back), summarizing

systematic observation

document typical cl. behavior/performance, unusual behavior, and used to confirm results of another assessment

observation cannot use

meaning of behavior

inner-rater reliability

80% or higher, degree of agreement b/t ratings of 2 independent observations viewing same behavior

observation method 1

checklists- record if behavior is present or absent, little room for interpretations

observation method 2

rating scale- can indicate degree of behavior present, easy to administer and score, personal bias

observation recording techniques- 4

1. interval- time blocks to observe

2. tally- record number of times behavior is observed

3. duration- record how long each behavior lasts

4. instantaneous time sampling- observer scans each subject and notes engagement

TX goals

broad, lead to pt outcome

pt outcome

end result

writing goals

general terms- increase, decrease, improve, etc.

writing objectives

condition (can have more than 1), criteria (can have more than 1), behavior (only 1)

types of records

pt records (the chart), health records

progress notes

SOAP, narrative note

types of documentation notes

session, progress, discharge