Assessment and Documentation

Question 1

4 main variables that affect the child’s ability to cope:

Answer 1

1. Child Variables
2. Family Variables
3. Illness Variables
4. Medical Experiences

Question 2

Child Variables

Answer 2

§ Temperament
§ Coping Style
§ Age (6 months to 24 months is most at risk, school agers are the most adaptable)
§ Gender

Question 3

Family Variables

Answer 3

§ Parental Anxiety & Distress
§ Family Characteristics
§ SES

Question 4

3. Illness Variables

Answer 4

§ Chronic vs. Acute
□ Acute- broken bone,
□ Chronic- diabetes,
§ Length of Hospitalization

Question 5

4. Medical Experiences

Answer 5

§ Exposure to Invasive Procedure
§ Pervious hospitalization

Question 6

In order to make an accurate assessment, the child life specialist must have knowledge of:

Answer 6

1. Child growth & development
   2. Potential impact of stress & hospitalization
   3. Family systems theory, child development theories
   4. Therapeutic play (benefits of)
   5. Be able to effectively communicate & establish therapeutic relationships with others
   6. Guide children in play experiences
   7. Gather information from a variety of sources

Question 7

Assessments come from what 3 sources?

Answer 7

○ Healthcare Team (also Medical Records)
○ The family
○ The child

Question 8

Stress Potential Variables

Answer 8

1. Healthcare Variables
   ○ Child’s response to healthcare, Diagnosis, nature of current & anticipated symptoms, anticipated treatment & procedures, course of child’s recovery or deterioration, number & type of health care professionals involved
2. Child Variables
   ○ Developmental vulnerability, age, mobility, culture & language
3. Family Variables
   ○ Family support system, socio-economic status (SES), culture & beliefs

Question 9

Planning Child Life Care: Assessment level 1

Answer 9

Stable medical condition with good prognosis, good family support

Question 10

Planning Child Life Care: Assessment level 2

Answer 10

Changes in behavior, length of hospital stay, anticipated future admissions, parental concerns, family’s inability to provide consistent support.

Question 11

Planning Child Life Care: Assessment level 3

Answer 11

Chronic diagnosis. Even if familiar with hospitalization and medical procedures, the chronic nature of illness entailed many future admissions, future treatments, and possibly premature death.

Question 12

Planning Child Life Care: Assessment level 4

Answer 12

If the child experiences great distress or discomfort. If child is likely to experience invasive and unfamiliar procedures or experience unpredictable events. The child had a complex medical condition or decreased family support.

Question 13

Planning Child Life Care: Assessment level 5

Answer 13

Imminent or recent intensive care stay, trauma, emergency room care. Those whose life situations were challenging and whose emotional needs were not being met. Those showing obvious signs of being emotionally overwhelmed. Those in a medical crisis or end-stage of their disease. Those with no family support.

Question 14

Why is documenting important?

Answer 14

Leaving footprints in your work

Question 15

APIE note

Answer 15

§ Assessment
§ Plan
§ Intervention
§ Evaluation

Question 16

SOAP note

Answer 16

§ Subjective
§ Objective
§ Assessment
§ Plan

Question 17

Sticky Issues in Charting

Answer 17

• Value judgments
• Presuming the Physician’s role
• Meaningful language
• Having incomplete information
• To chart or not to chart?
• Sharing information with parents. Parents can read the chart
• The chart is a legal document! It is permissible in court
• Stick to the facts
• Appreciate confidentiality and family’s privacy