Lecture notes
Lecture notes and additional notes - OT and Chronic Diseases (OCT213)
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OCT213 NOTES:PERFORMANCE SKILLS/ COMPONENT ASSESSMENTS
INTRODUCTION
WHY do assessments?
● Assessments show the exact extent and e ect of the injury or disability
● An assessment forms the base on which to plan interventions
● Assessments wi provide information with regard to the expected level of recovery
● Need to link to your understanding of the diagnosis and its prognosis
● Re-assessments wi show the progress or lack of progress made in your interventions
Need to understand what the client can and can’t do.
What their abilities are
After doing the assessments, you can plan the interventions
Need to understand the client’s pathology – have an idea what to expect from the client
Do assessment and then always do a re assessment (after a few weeks)
WHAT assessments can be done?:
● INFORMAL OBSERVATIONS – more subjective
Informal – observation ski s (observing clients – what is their balance, posture like?) – reasoning around your
observations
Keep notes from a observations
● FORMAL – more objective
Formal – forms that you in (SMME) (more objective – do it in a certain way and you score them)
● STANDARDIZED – must be conducted in a standardized manner
Standardized – use speci c paper, sit in a certain way – there’s regulations
Informal Assessments:
● These assessments are done using observation ski s as the client goes about doing activities and tasks within the
various occupational performance areas
● There are no speci c forms used to take note of the results of observations but observations must be noted by
the student and made use of in intervention planning and applications
● While observing the client doing their di erent activities you should be taking note of the which performance
ski /component is a ected, so as to guide you in planning further assessments \
● These assessments are move subjective
How are they dressed? What are they wearing? How did they walk towards you? How are they standing?
Write down at the end of the day your observations (your own piece of paper – write initials of clients and date)
con dentiality
,Formal Assessments:
● This type of assessment makes use of set equipment, forms and speci c procedures
● These assessments are more objective and easily repeatable
● Assessments are for speci c components or ski s
Standardized Assessments:
● Standardized assessments have been developed and are administered and scored in a standardized manner.
● Assessments must be conducted in a speci c way, using speci ed equipment, language and procedures.
Rules and regulations attached
● Observe the client engaging in their occupations / related activities and from those observations, using clinical
reasoning ski s determine which component /ski s to assess
● Always consider your client as a whole and not just ‘about’ the ski /component being assessed
Clinical reasoning ski s use your theory what you have learnt and then putting the observations and their pathology
your client as a whole
Using the 5WH questions
It is frequently de ned as the process where a physician gathers and synthesizes information, generates hypotheses and
formulates a clinical impression, prognosis, diagnosis, treatment, care and/or management plan
WHEN do you do assessments?:
● Informal observations should be taking place a the time
● Formal assessments are carried out
- At the beginning of the OT process
- During the intervention period if appropriate
- At the end of interventions, prior to your termination of interventions with the client
● By doing this you wi be able to take note of any improvement in ski s, or if little or not change is noted.
Informal – taking notes a the time (also writing rough notes)
Formal – happen at the start of your intervention and at the end of your intervention but even during the intervention
depending on the client and their intervention
WHERE do you do assessments?:
● Informal assessments /observations are done anywhere and a the time
● Formal assessments are done in the ward, or OT dept
WHO do you assess?:
, ● The client – so that you are able to plan appropriate interventions
● Your self – always need to be evaluating and re ecting on your own practice
HOW do you assess?:
Informal assessments
● Need to make use of good observation and clinical reasoning ski s
● When you observe something, always ask yourself 5 WH questions
● You need to keep record of your observations – keep good notes, make yourself some sort of record keeping
Formal assessments
● Always keep in mind the general principles that must be applied, no matter which component ski you are
assessing.
Principles - how to do stu
General Principles of Formal Assessments:
Environment
● Privacy
● Lighting and ventilation
● Appropriate
● Enough space
Equipment
● Must know what equipment to use
● Must know how to use the selected equipment
● Equipment must be in good working condition
● Must have a equipment at hand
Knowledge
● Must know what you are going to assess and how to do the assessment – plan and prepare ahead of time
● Must know how to record the information correctly
● Can discuss results with client if appropriate
Have a plan A, plan B and plan C
Procedure
● Explain to the client what you are going to do and why’
● Explain to the client what you expect or require from him
● Loosen or remove (if appropriate) tight clothing
, ● Observation of the client with regards to the component /ski being assessed
● Always make comparisons
● Do the assessments with con dence and as accurately as possible
● Record the information immediately and appropriately
● Do not do unnecessary assessments
Assessments must be:
Relevant
● With regards to the diagnosis, referral and what you expect from the intervention process
● Fit in with the diagnosis
Repeatable
● Speci ca y formal and standardized assessments
Recorded
● Clearly, neatly, dated and signed and in black pen
Retrievable
● Notes to be placed in clinical les or handed in to supervisors
● Information needs to be available to the intervention team if required
PERFORMANCE SKILLS/ COMPONENT ASSESSMENTS: SENSATION
Why assess sensation?:
● To outline the areas where sensation is intact, impaired or absent so as to provide a baseline for interventions
● To evaluate progress e.g. nerve injuries
● To determine if it wi be necessary to teach the client how to protect themself against injury and how to make
use of compensatory or preventative measure e.g. vision
● To determine whether a sensory retraining program is feasible
● Loss of sensation or sensory impairment may a ect the use of splints where sensory feedback is essential
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