The Assessment Process Part II Red book Chapter 5

Organizing and Interpreting Information Document client’s strengths AND needs Examples pg. 100 Be clear about the differences between information and inference

Information vs. Inference Information is raw data objectively obtained Therapist gathers objective and subjective information during the interview process and will report on the information gathered. Primary Secondary Inference is the therapist’s interpretation of the information Once adequate information is collected, the therapist makes inferences (applies meaning) to the information collected during the assessment process.

Reviewing the Findings with the client Present client with A summary of the purpose of the assessment Levels of performance demonstrated by the client during the assessment process What that performance means to the client in terms of day-to-day function

Recording the Assessment Findings in the Medical Chart Therapist should be able to answer yes to each of the questions on pg. 101 Any volunteers to read the questions aloud?

Reporting the Findings Most treatment teams have weekly updates on each client’s status The CTRS should plan to share information from the assessment that is critical and significant to the client’s care with the rest of the treatment team

Finalizing the Treatment Plan Every component of treatment in the treatment plan needs to be able to be traced back to an assessment finding.

Clinical Opinion Examples on pg 103

Ongoing Assessment Daily chart review Special orders or requests for recreational therapy services Progress Notes Orders

Client changes that may warrant a change in treatment plan Change in Health status Change in Privilege status Change in Activity status Change in Dietary status Change in Legal status

Written daily updates Two primary methods of keeping track of the daily changes (or non- changes) in client status Kardex Dept. file that includes standardized or non-standardized assessments Palm pilots Three ring notebooks Each client has their own record Information includes Daily shift change reports Client status during RT Participation patterns

Ongoing, Informal Assessment Must decide whether new information has the potential to impact treatment Example Casey Table 5.3 Page 106

Other Assessment Milestones Standardized assessment to measure a specific element that caused a question or concern during the regular assessment process Normally scheduled updates to previously administered assessments Standards (usually a federal law) Discharge assessments Post-discharge assessments

Discharge Assessments Gather information obtained about the client while in therapist’s care Determine most important information relating to the client’s needs, strengths, and status changes during care Review summary with client and/or family Write D/C summary Integrating this information with suggestions for next steps Finalize referrals for after D/C

Follow-Up Assessments Not common If they do occur at your facility Identify one or two areas you’d like to have assessed Usually nursing staff goes

Fin