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