Initial Assessments – as a conversation not a quiz

Session content:  What is an initial assessment  Starting strong  Following the patients lead  Initial assessment structure  FAQ from past students / therapists new to physical health

What is an initial assessment  Objective can vary between assessments  Information gathering  OPI identification  Is OT indicated / what do they need from us?  It’s kind of like a maths equation: medical event / illness + ??? = optimal level of function

Starting strong  Introducing your role and aim of session  Introducing self to all people present in the room  Tailoring your definition of OT to suit the context of the assessment

Following the patient’s lead  Don’t expect the conversation to be necessarily linear!  Most people new to this style of assessment worry that they won’t gather all the appropriate information the first time or will forget to ask a question!  I have been working and doing these assessments for 8 years and I still forget to ask the odd question here and there – who cares! We can’t be perfect all the time!  Going where they lead and picking guiding questions to work from.

Initial Assessment Structure

Consent / Notes / Role  How to document when the patient can’t give informed consent  Why read the notes  What you could document when you don’t see the patient at this point

Client and Family Perspective  This is important as you need to give the patient and their family the opportunity to voice their perspectives and make their wishes known  Documenting this is very important also, and the way that you do this will influence how others see the person and their family  “we create the truth with our notes”  MY KEY RULES:  NO JUDGEMENT  NO VALUE JUDGEMENTS  EMPATHISING WITH THE PATIENT DOES NOT MEAN THAT WE CONDONE THEIR ACTIONS / LIFE CHOICES, JUST THAT WE UNDERSTAND WHERE THEY ARE COMING FROM

Home Environment  Specifics are important – influences equipment prescription / home supports  This information will likely be forwarded on through subsequent admissions  Time saver in the next admissions

Pre-admission Occupational Performance  Self-care / Leisure / Productivity  How to ask delicate / personal questions – changes depending on the age or background of the patient  Specifics like standing to shower in a cubicle is very different to standing to shower in a shower over the bath

Current Occupational Performance  Abilities on the ward  Detail is important  State if you observed it / read it in notes (cite the date of the entry) / patient reported it to you

Occupational Performance Issues (OPI’s)  Can clarify in your mind what direction you are heading in with the patient during their admission  Clear identification of the issues is important as it allows the other members of the team to see

Goals  What does the patient want to get out of the admission?  Goals will be discussed further in a separate teaching session

Analysis / Plan  Analysis demonstrates your clinical reasoning  Rest of the assessment should be leading to that point / clear flow to that point  If you are going to discharge the patient you should have a clear reason why written in this section  My rule – no new information should appear in this section – it should be mentioned in the preceding sections  Plan with time frames and who you will be liaising with if appropriate

FAQ from students / therapists new to physical health  How do I get them back on track?  How do I record their complaints?  How do I ask about cognition without freaking out the patient?  How do I ask tactfully about toileting / continence without embarrassing them?  What if I forget to ask a question?  What if I can’t get all the information straight away – how do I record that?  They talked a lot but didn’t give me the information that I wanted – what do I write down?  They got so angry / upset at me / during the session for asking questions I had to leave – how do I document that?

Have I missed anything?  Please let me know if you have any other questions or if there are things that I could add to make the presentation better – flick me a message on the website and I will have a look! Have a lovely day Sonya