Evaluation, Interpretation, and Goal Writing Flashcards
The evaluation process is used to determine…
What an individual wants and needs to do.
What the individual is currently able to do.
What supports and barriers influence occupational performance and participation.
Occupational therapists conduct evaluations for many purposes:
Screening
To determine the scope and frequency of occupational therapy services
To establish goals and develop intervention plans
To assess progress toward goals
What is a screening?
Screenings are conducted to determine if a child would benefit from a formal evaluation for occupational therapy services.
What methods can be used to obtain the parent and child’s perspective?
Interviews
Formal assessment tools
Observation
Picture taking methods
The evaluation process includes…
Occupational profile
Evaluation plan
Analysis of occupational performance
- Collecting data through various assessment tools and strategies
Interpretation of findings
Refining hypothesis
Documenting findings
Establishing goals
Designing interventions
What are methods of evaluation?
Standardized assessment tools
- Norm-referenced
- Criterion-referenced
Non-standardized assessment tools
Clinical Observations
Interviews
The OT synthesized the data from the evaluation and answers what questions?
Would this child benefit from occupational therapy services?
What are the appropriate outcomes for this child’s occupational therapy services?
Which occupational therapy theory and/or frame of reference(s) will be used to guide the intervention planning for this child?
What is the best context and/or environment for this child’s occupational therapy services?
Does more information need to be collected from the child, parent, or other team members before decisions can be made?
Does the child needed to be referred for services other than occupational therapy?
What is the purpose of documentation?
The purpose of documentation is to communicate information about the client, explain recommendations, and create a chronological record associated with the services provided.
Documentation should reflect the occupational therapist’s clinical reasoning.
What is included in the evaluation report?
Referral source and information (e.g., date of and reason for referral).
Relevant client information (e.g., name, identification number, medical history, and/or diagnosis, if applicable).
Description of the client’s occupational profile.
Description of the process and assessment tools used to complete the analysis of occupational performance.
Summary of the findings from the assessment process and tools (e.g., assessment scores).
Description of the occupational therapist’s interpretation (e.g., judgment about how specific performance skills, performance patterns, contexts/environments, client factors, and activity demands influence occupational performance and participation and is related to the client’s occupational profile).
Recommendations (e.g., whether or not occupational therapy services are needed; need for assistive technology or accommodations or modifications).
Occupational therapist’s signature (e.g., first and last name, and professional designation).
When writing goals consider…
the timeframe.
the person.
the daily occupation or routine.
the specific context.
What are types of goals?
long term and short term (benchmarks)
