1. The Assessment Process Part I
Red book
Chapter 5

2. The Assessment Process
Process of assessment is influenced by
Facility policies
Department policies
Regulatory requirements
Timeframes
Medicare
Intake assessment within 72 hours of admission
Nursing homes
Assessment within 14 days
Rehabilitation settings
Varies: 72 hours

3. Service vs. Unit Service Unit
A treatment team that is headed by physicians with the appropriate support staff, such as nursing staff, therapists, and assistants
Unit
A group of beds within a facility that share a common location and support staff (nurses, therapists, and assistants)
Admit clients from numerous services
Each service and unit develops its own criteria for admission

4. Assessments prior to therapist intake
A physician, nurse consultant, or PA conduct the initial assessment and make a recommendation concerning the appropriateness of admission.
Collect basic information
Starts a new chart or adds to existing chart
Documents/confirms advance directive
Admission often dependent on
Funding
Bed availability

5. Which clients will be seen by Rec. Therapy?
Standing order
Specific request
A recreational therapy policy that clearly communicates to the team physician and members of the interdisciplinary treatment team the guidelines for recreational therapy intervention is strongly encouraged.

6. Initial Screening vs. Intake Assessment
Written thresholds required for a client to qualify for services
If RT is not recommended, you must clearly document why and schedule a follow-up (if appropriate)
Intake Assessment
Guided interview process
May contain standardized assessment as a component

7. Intake Assessment Determines client’s Strengths Needs Resources
Info critical to developing individualized treatment plan
May contain standardized testing tool.
Unlike standardized testing tool, intake assessments are not necessarily intended to be balanced (content validity), but are meant to reflect the scope of responsibility of the therapist

8. Gathering Information
Activity Level
As determined by the physician
Activity allowed
Primary diagnoses
Secondary diagnoses
R/O diagnoses
Interview scheduling

9. Interview Process
Three primary tasks associated with your first formal contact with the client
Determine nature of the client’s problem and identify areas, within the scope of practice, which may need to be addressed
Develop an initial relationship with the client
Provide the client with information
Including an expectation of the type of treatment and services that will make up the client’s treatment plan
Table 5.1
Pg. 94

10. Interview Warm-Up Speaking to the correct client
Communicating in the method that best supports the client
Creating a comfortable climate to put the client at ease
Establishing appropriate therapeutic boundaries
Observing the client’s
Appearance
motor function
speech pattern
thought process
Affect
Mood
Verbal communication
Non-verbal communication

11. How well did you develop rapport?
Othmer and Othmer (2002) Checklist
Table 5.2
Page 96

12. Interview Phase In-house intake form will guide process
Therapist needs to pay attention to
Content
Information provided by the client during the interview
Process
Non-verbal activity of the client in response to the interview

13. 15 Techniques to guide interviews
Open-ended questions
Transition
Closed-ended questions
Self-Revelation
Reflection
Positive Reinforcement
Facilitation
Reassurance
Silence
Advice
Confrontation
Clarification
Interpretation
Summation
Explanation

14. Content to ACTION Pair up by birth month
One person is the therapist, one is the client
Develop questions to ask
Not too clinical – cause assessments aren’t done in front of a room full of people
TOGETHER, so client is not blindsided in front of class
You are yourselves
More of a friendly interview
Throughout the interview the therapist must use at least three of the techniques discussed

15. Interviewing clients with cognitive disorientation
Guidelines
Kaplan, Sadock, and Grebb (1994)
Feil and DeKlerk-Rubin (2002)
Page 99

16. What to do with Conflicting Information??
Double check client’s verbal report against information already in chart
If there is a conflict, you must confirm one of the following:
Client is having trouble with basic mental orientation
Material was incorrectly transferred from the medical chart to your intake form
The medical chart contains incorrect or out of date information

17. Outcomes of Interviews
Client should feel they were able to convey what they feel is important information about themselves to you.
You should leave the client feeling that you were empathetic and an interested listener (without having violated any boundaries)
You have obtained the information you need to begin the process of determining appropriate clinical interventions

18. As you leave their room/bed...
If possible, let them know the next time they will see you for treatment
Good to leave a schedule if possible