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Initial Assessments – as a conversation not a quiz

Initial Assessments – as a conversation not a quiz. Session content:. What is an initial assessment Starting strong Following the patients lead Initial assessment structure FAQ from past students / therapists new to physical health. What is an initial assessment.

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Initial Assessments – as a conversation not a quiz

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  1. Initial Assessments – as a conversation not a quiz

  2. Session content: • What is an initial assessment • Starting strong • Following the patients lead • Initial assessment structure • FAQ from past students / therapists new to physical health

  3. What is an initial assessment • Objective can vary between assessments • Information gathering • OPI identification • Is OT indicated / what do they need from us? • It’s kind of like a maths equation: medical event / illness + ??? = optimal level of function

  4. Starting strong • Introducing your role and aim of session • Introducing self to all people present in the room • Tailoring your definition of OT to suit the context of the assessment

  5. Following the patient’s lead • Don’t expect the conversation to be necessarily linear! • Most people new to this style of assessment worry that they won’t gather all the appropriate information the first time or will forget to ask a question! • I have been working and doing these assessments for 8 years and I still forget to ask the odd question here and there – who cares! We can’t be perfect all the time! • Going where they lead and picking guiding questions to work from.

  6. Initial Assessment Structure

  7. Consent / Notes / Role • How to document when the patient can’t give informed consent • Why read the notes • What you could document when you don’t see the patient at this point

  8. Client and Family Perspective • This is important as you need to give the patient and their family the opportunity to voice their perspectives and make their wishes known • Documenting this is very important also, and the way that you do this will influence how others see the person and their family • “we create the truth with our notes” • MY KEY RULES: • NO JUDGEMENT • NO VALUE JUDGEMENTS • EMPATHISING WITH THE PATIENT DOES NOT MEAN THAT WE CONDONE THEIR ACTIONS / LIFE CHOICES, JUST THAT WE UNDERSTAND WHERE THEY ARE COMING FROM

  9. Home Environment • Specifics are important – influences equipment prescription / home supports • This information will likely be forwarded on through subsequent admissions • Time saver in the next admissions

  10. Pre-admission Occupational Performance • Self-care / Leisure / Productivity • How to ask delicate / personal questions – changes depending on the age or background of the patient • Specifics like standing to shower in a cubicle is very different to standing to shower in a shower over the bath

  11. Current Occupational Performance • Abilities on the ward • Detail is important • State if you observed it / read it in notes (cite the date of the entry) / patient reported it to you

  12. Occupational Performance Issues (OPI’s) • Can clarify in your mind what direction you are heading in with the patient during their admission • Clear identification of the issues is important as it allows the other members of the team to see

  13. Goals • What does the patient want to get out of the admission? • Goals will be discussed further in a separate teaching session

  14. Analysis / Plan • Analysis demonstrates your clinical reasoning • Rest of the assessment should be leading to that point / clear flow to that point • If you are going to discharge the patient you should have a clear reason why written in this section • My rule – no new information should appear in this section – it should be mentioned in the preceding sections • Plan with time frames and who you will be liaising with if appropriate

  15. FAQ from students / therapists new to physical health • How do I get them back on track? • How do I record their complaints? • How do I ask about cognition without freaking out the patient? • How do I ask tactfully about toileting / continence without embarrassing them? • What if I forget to ask a question? • What if I can’t get all the information straight away – how do I record that? • They talked a lot but didn’t give me the information that I wanted – what do I write down? • They got so angry / upset at me / during the session for asking questions I had to leave – how do I document that?

  16. Have I missed anything? • Please let me know if you have any other questions or if there are things that I could add to make the presentation better – flick me a message on the website and I will have a look! Have a lovely day  Sonya

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