1. The Assessment Process Part II
Red book
Chapter 5

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

3. 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.

4. 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

5. 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?

6. 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

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

8. Clinical Opinion
Examples on pg 103

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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. Fin