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Laura > FINAL TEST > Flashcards

FINAL TEST Flashcards

1
Q

WHAT IS THE TR ASSESSMENT REPORT/ SUMMARY

A

Summarizes information obtained during ASESSESMENT

Follow format laid out by AGENCY – there is not a consistent format used in all settings

Becomes part of individual’s OFFICAL CHART ; often shared with other members of the team

Culmination of all your assessment efforts; representsYOU, YOUR DEPARTMENT AND TR PROFESSION

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2
Q

TRUE OR FALSE : ASSESSMENT REPORTS ARE PROFESSIONALLY WRITTEN?

A

TRUE :

Professionally written, using appropriate language; written in 3rd person

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3
Q

TRUE OR FALSE : THE ASSESSMENT REPORT DOES NOT SUMMARIZE FACTUAL INFORMATION ?

A

FALSE

the assessment DOES Summarizes factual information; includes some additional interpretation and recommendations at end

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4
Q

what should you avoid when writing an assessment report?

A

avoid to much TR “jargon”

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5
Q

how is an assessment report typed?

A

single space-spaced; generally 2-3 pages maximum

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6
Q

what should assessment reports always be?

A

professional and error-free

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7
Q

what is the typical format of an assessment report?

A 
Participant name 
Dates of the assessment
Reason for referral (if applicable- in this case participant self referred)
Background information
Methods used to gather information
Results of assessment
Summary and interpretation
Recommendations
Signature(s) and date(s)
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8
Q

what comes before the intervention plan?

A

assessment reports

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9
Q

What is ecological assessment

A

assessing participants in their environment

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10
Q

what are the two types of ecological assessments?

A

BROAD

FOCUSED

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11
Q

what two questions does Broad ecological assessment involve ?

A

what do we know about the person ?

what do we know about their environment?

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12
Q

what is some Information gathered that is geared towards what do we know about the person ?

A 
strengths
Physiological
Emotional
Social
Cognitive
Physical
Spiritual
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13
Q

what is some Information gathered that is geared towards the external strengths in what we need to know about their environment ?

A 
Family
Home
World expectations
Opportunities for inclusion
Community resources
Friends and acquaintances
Community resources
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14
Q

what is a focused ecological assessment?

A

Looks at the participants abilities in relation to the demands in which he or she will be included for recreation

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15
Q

How do we bridge the gap between the participant and their environment to ensure successful participation?

A

Goals
Modifications
Supports
Strategies etc.

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16
Q

What are the 5 focused ecological assessment steps?

A

Task analyze the preferred recreation activitity

Identify the abilities

Identify the gaps

Identify services, interventions and supports (that will bridge that gap)

Develop participates plan

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17
Q

how many steps does the focused ecological assessment have?

A

5

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18
Q

in comparison give 2 things about Broad Ecological Assessment

A

Participant and environmental strengths

Participant leisure experiences

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19
Q

in comparison give 2 things about focused ecological assessment

A

focused on a specific goal

Bridging the gap so that participates can successfully participate

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20
Q

what are the advantages of ecological assessment ?

A

Person centered- person in their environment

Allows greater understanding of participant and their concepts

Provides directions for supports and services
Strengths based and authentic

Uses multiple methods(interview, observation, recording tools, tests/questionnaires

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21
Q

what are some disadvantages of ecological assessment ?

A

Time consuming

TR might have difficulty assessing participants in all environments

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22
Q

what are some current stats of TR Assessments study conducted by Kemeny, Hutchinson and Cooke?

A

80.0 % of respondents reported completing individualized assessments for their clients

The most frequently used assessment tools were the TRAA , followed by the lesuire assessment inventory

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23
Q

What some reason why the TR did not perform individualized client assessments?

A

Client shortened length of stay- _9%

Large caseloads per staff members- _18%

No agency requirement for a specific TR assessment- _31%

Only certain groups are assessed (by referral only)- __14%

Individualized assessment does not fit due to group focus- __22%

No assessment tool that suites the clientele- __6%

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24
Q

what are the 10 Issues with assessment implementation

A
  1. Lack of an adequate number of T.R. assessments for the variety of T.R. settings and participants
  2. Lack of high quality assessments that accurately measure behaviours and attitudes important to T.R. practice.
  3. Lack of assessment resources about where / how to obtain tools
  4. Lack of financial resources to purchase appropriate tools
  5. Lack of practitioner expertise in electing, administering, scoring, and interpreting results
  6. failing to match assessment information gathered with appropriate placement in to programs / services.
  7. Failing to measure change using the same assessment instruments.
  8. Shortened length of intervention for participants
  9. Increased job duties, leaving less time for assessment.
  10. Lack of opportunities for updated training.
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25
Q

what are some challenges a TR practitioner can face during the assessment ?

A

Become as informed as possible about assessment

Look for formal professional development opportunities re: assessment

Observe / consult with peers in the field about what works for them

Engage in self reflective practice about your assessment processes. What could you be doing better?

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26
Q

what are narrative notes?

A

A form of progress note

Very few format and structure guidelines

Other staff must read entire note, can be time consuming

Therefore, knowing what to document is key!

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27
Q

what is the content of narrative notes?

A

Progress towards attainment of client goal

Regression from attainment of client goal

New patterns of behaviour

Consistency of behaviour

Verbal information provided by the client

Successful or unsuccessful attempts at a task

Appropriate or inappropriate interactions with staff, peers, visitors

Client responses to questions, instructions, requests

Initiative with actions, ideas, problem-solving, decision making

Follow-through or lack of follow-through with commitment

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28
Q

what is the frequency of process notes based on ?

A

Agency regulations and requirements (i.e. daily, weekly)

TR staff-time usage (documentation time should be scheduled into your daily routine)

Delivery of quality services (timely documentation helps to facilitate communication amongst staff members

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29
Q

what are the 10’s of documentation ?

A 
confidential 
consecutive
contemporary
correct
centered on the participant
collaborative
complete
comprehensive 
concise
clear
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30
Q

Narrate this :

George attended painting program but was not able to hold a regular paint brush due to arthritis
TR gave George an adaptive paint brush with a thicker handle and he was able to continue painting

A

On April 9th, George attended a painting program. George appeared to have a good time and was socializing with peers. During the program, George found it difficult to hold a regular paint brush due to his arthritis. The TR recognized George’s difficulties. The TR provided George with an adaptive paint brush with a thicker handle which allowed him to continue painting. George successfully completed his painting. For future recreation opportunities within the painting program, George will have his own adaptive paint brush

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31
Q

Narrate this:

A

On April 9th Betty was asked to join the TR and other residents for “coffee and news” where her and other residents would drink coffee and discuss the local daily news. Betty declined the invitations to the the outing. TR noticed that Betty had not been coming to all group programs lately. Betty is a woman that usually participates yet suffers from great depression. Betty has been staying in her room with lights of and curtains closed. TR has discussed Betty’s performance to charge nurse which will refer Betty to the doctor and have the Doctor look at Bettys behaviours. TR will continue to visit Betty daily and encourage Betty to participate in daily activities.

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32
Q

Implementation involves what?

A

Following through with the intervention plan by offering the programs outlined

Documenting information about the participant during the process

Regardless of your setting (healthcare/community based) documentation is critical to communication, collaboration, rigorous evaluation, and service improvement.

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33
Q

True or false; a common expression in documentation is: if its not in writing, it didn’t happen

A

true

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34
Q

Documentation involves putting in writing the different elements of the therapeutic recreation process. What components are included?

A 
Referral
Assessment Summary
Intervention Plan
Progress reports/notes
Incident reports
Plan updates
Discharge summaries
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35
Q

what does the acronym SOAP stand for?

A

Subjective- info from the client
objective- info based from tr
assessment- conclusions based on TR’s professional opinion based on subjective and objective findings
plan- the measures taken to achieve a desired result

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36
Q

What are the 5 reasons why documentation in important?

A

Helps assure quality services

Facilitates collaboration with team and participant

Legal record

Ensures compliance with standards

Provides “PR for TR ” (Promoting what we are doing)

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37
Q

Frequency of documentation is determined by what?

A

Agency/departmental guidelines or requirements_

Staff time available

Opportunity for verbal communication between staff_

Occurrences which require documentation_

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38
Q

What are the 5 C’s of documentation

A

Comprehensive

collaborative

centered on the participant 
contemporary

consecutive

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39
Q

what are DARP notes?

A

Type of “focus charting”

Focuses on important elements of services (goals & objectives)

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40
Q

what are the benefits of DARP Notes

A

Ensures accountability
Enhances efficiency (avoid repetition)
Improves communication

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41
Q

what does the “D” stand for in DARP notes

A

D = Data (What the participant said; what behaviours or factual data you observe; your conclusions or interpretation

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42
Q

what does the “A” stand for in DARP notes?

A

A = Action (What you did)

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43
Q

What does the “R” stand for in DARP notes?

A

R = Response (How the participant responded to what you did)

44
Q

what does the “P” stand for in DARP notes?

A

P = Plan (Based on interaction, what immediate steps you plan to take)

45
Q

TRUE OR FALSE the discharge summary is usually the final form of documentation and evaluation ?

A

TRUE : The discharge summary is usually the final form of documentation and evaluation that a participant receives in an inpatient or outpatient facility.

46
Q

what type of information should the TR include on discharge and referral summaries

A

client goals services received by the client

client responses to functional interventions, leisure education, and recreation participation

remaining concerns

recommendations including any follow up, referrals, community resources, or post discharge instructions

47
Q

what question does the referral summary answer?

A

“how did we initiate services with the participant?”

48
Q

what are referral summaries

A

In inpatient settings referrals will typically come from the physician.

In other settings (outpatient) referrals might come from different professionals family members and even from the participants themselves

49
Q

what types of referral tests are there?

A

medical referral (healthcare based)

inclusion service referral (community based)
Recreation Service Self referral (healthcare or community based

50
Q

what is a incident report?

A

Each agency will have a social form for documenting accidents, incidents, and unusual occurrences.

Documentation and analyses of incidents as a part of risk management is required by legislation

51
Q

WHEN should we report an incident report?

A 
Client death or injury
Broken equipment (lift)
Runaway client
Medication error
Child abduction
Patient fall
Patient abuse
52
Q

WHAT do we report in a incident report?

A 
When and where the incident occurred
Findings at the scene
Care of client (pre and post)
Client comments
Who was notified
PREVENTATIVE STEPS
53
Q

what are the 6 guidelines fo documenting incident reports?

A 
Write objectively- the facts
Include only essential information
Avoid opinions
Assign no blame
Avoid hearsay or assumptions
File the report properly
54
Q

What are the documentation guidelines?

A

Know and follow agency requirements re: charting
format

Use simple terms, avoiding jargon and unnecessarily complicated words and phrases
Use appropriate, agency-accepted abbreviations
Describe, rather than interpret, using overt behavioural descriptions
Never falsify chart or tamper with a record
Be as precise as possible (e.g. “six times in one hour”, not “often”); avoid words such as “bad”; “good”; “average”; “better” that may mean different things to different readers
Avoid vague phrases such as “kind of”; “seems to be” etc.
Use correct grammar and spelling
Follow agency policies regarding electronic records
Write legibly, always in pen
Correct errors using agency format (generally a single line drawn through, “initials” written above or next to it, correction made, and initialed)
Never leave blank spaces or lines; don’t use ditto marks
Chart entries chronologically
Date and sign each entry, following agency protocol
Seek input from participant and team members when relevant
Ask yourself “would I be comfortable in having participant read this?”
Don’t delay charting, as important information may be forgotten!

55
Q

What does the acronym AND stand for?

A

Allow natural death

56
Q

what does the acronym c/o stand for?

A

complaints of

57
Q

what does the acronym d/c stand for?

A

discharged

58
Q

what does the acronym EDD stand for?

A

estimated date of discharge

59
Q

what does the acronym HPI stand for?

A

History of presenting illness

60
Q

what does the acronym a.c stand for?

A

before meals

61
Q

what does the acronym hs stand for?

A

bedtime

62
Q

what is the term :
Umbrella term used to describe activity or action-oriented services including recreation therapy/ occupational therapy; usually applied in psychiatric facilities

A

Action Therapy

63
Q

what is the term:
Act of recording client assessments and interventions in the client’s chart. The chart is a permanent record that is considered a legal document and is audited to evaluate changes and quality of care

A

Documenting

64
Q

what is the term :

The act of written documentation (often referred to as progress notes) on the clinical record or chart of a particular client

A

charting

65
Q

what is the term to this definition ?
Intervention directed and structured by a recreation therapist to encourage clients to take action to restore their health

A

Prescriptive Activity

66
Q

what is the term to this definition ?

A person’s feelings, tone or mood; one’s emotional response

A

affect

67
Q

what is the term to this definition ?

Absence or near absence of any signs of affective expression

A

Flat

68
Q

Uncontrollable impulse to perform an act repetitively

A

compulsion

69
Q

Growth-oriented therapeutic approach developed by Carl Rogers. The role of the helper is to display unconditional positive regard for clients.

A

Person Centred Therapy

70
Q

Condition characterized by purposeless, restless activity such as pacing. May serve to release nervous tension associated with stress, anxiety, or fear

A

Agitation

71
Q

Activity that is dysfunctional or counterproductive in coping effectively with stress

A

Maladaptive behavior

72
Q

Confused state of consciousness often characterized by delusions/hallucinations

A

Delirium

73
Q

Taking into account the whole person interacting with the environment

A

Holistic

74
Q

Inability to experience pleasure from activities that usually produce pleasure

A

Anhedonia

75
Q

Confused as to time, place, and person (the position of the self in relation to other persons); characteristic of organic mental disorders

A

Disoriented

76
Q

Weak or lacking normal tone or vigor

A

Atonic

77
Q

Learning by watching the behavior of other persons; demonstration of a task, skill, or desirable behavior in order to teach another person

A

modeling

78
Q

Unpleasant state of apprehension, tension or uneasiness from a vague or largely unknown or unrecognized source; characterized by increased heart rate, trembling, sweating, and disrupted breathing

A

Anxiety

79
Q

Altered state of consciousness characterized by an exaggerated feeling of well-being, with or without foundation.

A

Euphoria

80
Q

Spreading of a behavior within a group due to reducing restraints about performing the behavior after seeing others doing it

A

Contagion

81
Q

Behavioral act with the goal of doing injury or harm to a person or object

A

Aggression

82
Q

Charting done by members of the interdisciplinary team that indicates the progress, or lack thereof, being made by the client, patient, or resident

A

Progress Notes

83
Q

People’s belief that they can succeed at something they want to do

A

Self Efficacy

84
Q

Method of charting, which designates the four parts of each entry in a problem-oriented record: subjective data, objective data, assessment, and plan

A

SOAP

85
Q

what does the acronym PRN stand for?

A

as needed

86
Q

what does the acronym Q stand for?

A

every day

87
Q

what does the acronym Q.H stand for?

A

every hour

88
Q

what does the acronym BM stand for?

A

bowel movement

89
Q

what does the acronym Dx stand for?

A

Diagnoses

90
Q

what does # stand for?

A

fracture

91
Q

what does the acronym f/u stand for

A

follow up

92
Q

what does the acronym SOB stand for?

A

shortness of breath

93
Q

what does the acronym BKA stand for?

A

BELOW KNEE AMPUTATION

94
Q

what does the acronym AKA stand for?

A

ABOVE KNEE AMPUTATION

95
Q

what does the acronym CA stand for?

A

CANCER

96
Q

what does the acronym MI stand for?

A

MYOCARDIAL INFRACTION

97
Q

what does the acronym TKR AND THR stand for?

A

TOTAL KNEE REPLACEMENT

TOTAL HIP REPLACEMENT

98
Q

what does the acronym O2 stand for?

A

OXYGEN

99
Q

what does the acronym CVA stand for?

A

CEREBROVASCULAR ACCIDENT (STROKE)

100
Q

what does the acronym ROM stand for?

A

RANGE OF MOTION

101
Q

what does the acronym ADL stand for?

A

ACTIVITIES OF DAILY LIVING

102
Q

what does the acronym W/C stand for?

A

WHEELCHAIR

103
Q

what does the acronym RW stand for?

A

ROLLATOR WALKER

104
Q

what does the acronym MCI stand for?

A

MILD COGNITIVE IMPAIRMENT

105
Q

what does the acronym SMMSE stand for?

A

STANDARDIZED MINI MENTAL STATUS EXAM

106
Q

what does the acronym MOCA stand for?

A

MONTREAL COGNITIVE ASSESSMENT

107
Q

what does the acronym CDT stand for?

A

CLOCK DRAWING TEST

Laura (3 decks)

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