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OT evaluation,

assessment and
treatment plan

Occupational Performance
Performance areas
Performance components
Performance context

Steps/Stages in Occupation
Therapy process

Clinical Reasoning
Can be defined informally a how we
think about how we do.
Gillette and Mattingly:
Mechanistic: closely allied with the
practice of medicine and address factors
such as how body works biomechanically
Phenomenological: the experience of
being in the world or the life of the
individual as perceived by that person

Fleming: three tracks used by the

expert clinician to organize and
process data
Procedural reasoning
Interactive reasoning
Conditional reasoning

Clinical reasoning in context

Pressure for cost containment and
reduction of unnecessary services
have forced the therapists to divide
their attention between needs of the
client-patient and the practical
realities of health care
reimbursement and documentation.

Client centered practice

Involving patients and clients in
identifying their own goals and in
making decisions about their own
goals and in making decisions about
their own care and treatment

Teamwork within OT


Services to be provided
by personnel who have
demonstrated service
In the interest of
rendering the best care at
the least cost, OTR may
delegate tasks to COTA
Retains final responsibility
for all aspects of care
including doicumentation

Administration of selected
screening instruments or of
assessment such as ROM, ADL
Intervention in the areas of ADL,
work, Play etc
Facilitation of transition
Assistance with the
development of a plan for
discontinuation of service
Contribution to documentation
Education of the patient, family
or community about OT services

OT aides
Teamwork with other professionals

Ethics issues confronting in practice:
Cost containment policies that
jeopardized patient care
Inaccurate or inappro. Documentation
Improper or inadequate supervision
Provision of treatment to those not
needing it
Colleagues violating patient

Treatment context
Refers to the environment in which
treatment occurs, an environment
that includes the physical setting and
the social, economic, cultural and
political situation that surrounds it.

Refers to the process of obtaining
and interpreting data necessary for
This includes planning for and
documenting the evaluation process
and results.

Refers to specific tool or
instruments that are used during the
evaluation process.

Continuum of health care

Inpatient settings
Acute care inpatient
Inpatient Rehabilitation context

Acute rehabilitation
Sub-acute rehabilitation
Skilled nursing facility

Continuum of health care

Residential care
Home Health
Home and community based therapy
Day treatment
Work site therapy programs
Industrial rehabilitation

Methods of assessment
Medical records


Treatment Planning
The purpose of Occupational Therapy
is to help learn or relearn essential
occupational performance tasks in the
areas of ADL, work, and play or leisure
that will enable them to live as
independently as possible.
A treatment plan is the design or
proposal for a therapeutic program.

Treatment planning process


Assess, analyse, and identify problems

Explore prospective solutions and develop
treatment goals and objectives
Design and implement a plan of action-the
treatment plan
Assess the outcomes of the plan and modify
it if necessary
Terminate treatment when the objectives
have been achieved or treatment is no
longer feasible

Treatment planning process

Data gathering
Data analysis and problem
Selecting a practice Model or
Treatment approach

Selecting and Writing

Treatment Goals and

Objectives: steps towards achieving
Writing Treatment objectives
Terminal behaviour

Selecting Intervention
Implementing the treatment plan
Reevaluating the patient and the
Treatment plan
Revising the treatment plan
Discharge planning
Terminating treatment

Purposes of documentation:
It facilitates effective treatment
It justifies reimbursement
It stands as a legal document
It provides communication among the
patient, the treatment team and the family

Hence it has legal, ethical, and

financial ramifications.

Guidelines for
Therapist should consider the
audience for which documentation is
Important to consider who will read
this documentation and who will
benefit from it.
Depend on the setting, the consumer,
the payer, and other providers.

Guidelines for

The rules for documentation in any work

setting must be built on an understanding of:
The needs of the consumer (the patient, the
family, or significant others)
The other team members (nurses,
physiotherapists, social workers etc)
The requirements of reimbursers (Medicare,
Medicaid etc)
Accreditation and government regulations
(State and local government agencies

RUMBA test
Was originated by AOTA in the 1070s
as a method used in quality
Has developed further to be used as
a method of self assessment not only
in quality assurance but also in
documentation, intervention, and

RUMBA for documentation

R= Is it Relevant?
U= Is it Understandable?
M=Is it Measurable?
B= Is it Behavioural?
A= Is it Achievable?

R= Is it Relevant?
Reports should reflect functional
goals and achievements because
these indicate the true relevance of

Is it Understandable?
Several dos and dont for the documentation.
Must be readable and therefore writing must be
Jargon should be avoided
Sentences should be concise, succinct, and
constructed using proper grammar and spelling.
Contrary to early professional standards in
documentation, it is becoming more acceptable to use
the first person in sentence structure; that is this
therapist applied or I have determined.
Don not use noncommittal language; that is it
seeems or it appears that.

M=Is it Measurable?
Goals and statements should be used
in measureable terms.
Other professionals can understand
the measures being used.
Measurements should be in terms of
frequency and duration etc.

Is it Behavioural?
Otists are trained to be fine
observers of behaviour.
Behaviours are those occurrences
that are seen and can be measured.
The words friendly, depressed,
appropriate and unmotivated do not
describe behaviour.

Is it Achievable?
At this step, Otist should try to step outside the
situation and look at the goal statements from
the perspective of the reimburser or accreditor.
The Question is: Is this plan or goal achievable
for this person, given the time constraints
imposed by reimbursement or regulatory
standards? If answer is no then the goal is not
realistic, given the treatment setting and
constraints, and the documentation should be

Problem oriented medical

record (PMOR)
Developed by Weed (1971) as a
means of providing structure for
progress note writing.
The SOAP method for writing
progress notes is commonly used in
medical institutions.
The structure of a SOAP note is as

The structure of a SOAP note is

as follows:
S= Subjective: the therapist records
information as reported by the
patient, the family, or significant
other. This information might include
what a patient says that cannot be

The structure of a SOAP note is

as follows:
O= Objective: the therapist records
measurable, observable data, usually
obtained through formal assessment
or evaluation tools. Specific medical
information and history are included

The structure of a SOAP note is

as follows:
A= Assessment: the therapist
records his or her professional
judgment or opinion as to functional
expectations or limitations based on
the objective data noted in the
previous section.

The structure of a SOAP note is

as follows:
P= Plan: the therapist records a
specific plan of action to be followed
to resolve problems. This section
may include short or long term goals,
how long treatment should be
provided, and how often the patient
should receive treatment.

This format may be used for initial
notes, interim or progress notes and
discharge notes.
Under POMR system, service notes are
not written; instead, members of the
treatment team write SOAP notes to
address those problems that are
appropriate to their interventions.

Uniform Terminology
The use of standardized UT can assist in
avoiding disparity in the types of coverage
from one region to another.
It facilitates review for reimbursement in that
reviewers are accustomed to the
Can impact on standards, reimbursement,
management and research.

Classification codes
International Classification of
Impairments, Disabilities, and

Arenas for communication

Community agencies
Residential agencies
Schools: Individual Education
Program (IEP)


Computerized medical records are standard

in many health service organizations.
Computerization requires standardization
and standardization can improve reliability.
These systems are constantly being updated
to meet the demands of administrators,
payers, and governing bodies.
Computerization has the potential to
become a cost-benefit measure within the
health care organization.