Occupational therapists cannot work with any patient because the patient may have a therapeutic need; patients must be referred. Patients are referred to occupational therapy by a variety of sources, including family members, caregivers, physicians, health care centers, and/or employers. The rules and regulations regarding occupational therapy referrals vary from state to state.
The occupational therapist completes the evaluation, including administering evaluation tools, scoring and interpreting the results, and writing the evaluation report. An occupational therapist can use a standardized assessment such as the Peabody Developmental Motor Scales, Functional Independence Measure (FIM), or the Sensory Profile. If a standardized assessment is used, then the therapist needs to follow the assessment word for word and step by step.
An occupational profile is the initial step in the evaluation process and consists of a description of the client’s history, performance patterns, performance skills, roles, interests, values, needs, priorities, support system, challenges, and strengths. The analysis of occupational performance consists of data obtained about the client using a variety of evaluation tools and strategies, such as direct observation or the administration of standardized or non-standardized assessments to measure specific impairments of body functions and structures. The client’s reasons for seeking services, strengths and concerns in relation to performing occupations and daily life activities, areas of potential occupational disruption, supports and barriers, and priorities are also identified.
Occupational performance analysis is the step in the evaluation process during which the client’s assets and problems or potential problems are more specifically identified. Actual performance is often observed in context to identify supports for and barriers to the client’s performance. Performance skills, performance patterns, context or environment, client factors, and activity demands are all considered, but only selected aspects may be specifically assessed. Targeted outcomes are identified. Depending on the client’s needs, assessment tools are selected to measure client factors, performance skills, performance patterns, and activity demands.
Targeted outcomes are determinants of success in reaching the desired end result of the occupational therapy process. The outcome assessment information is used to plan future actions with the client and to evaluate the service program (i.e., program evaluation). Goals are developed in collaboration with the client and need to reflect occupational performance problems relevant to the client’s wanted outcome. Goals need to be objective, measurable statements with an evident time frame and preset objective methods to measure progress.
Intervention in occupational therapy refers to the use of specific activities or techniques to help clients achieve their targeted outcomes. Intervention is provided at four different levels, which include adjunctive, enabling, purposeful activities, and occupation-based activities. The occupational therapist collaborates with the client to select the most appropriate level of intervention based on the client's needs, goals, and evidence-based practice.
The intervention plan guides the actions taken and is developed in collaboration with the client and determines the selection of specific skilled activities used to address the client’s goals. The intervention can be categorized as preparatory activities and meaningful occupations/ activities. Additionally, activities used as interventions are components of client-directed daily life activities.
Intervention implementation refers to the ongoing actions taken to influence and support improved client performance and participation. Interventions are directed at identified outcomes. The client’s response is monitored and documented.
Re-evaluation consists of a reappraisal of the client’s performance and goals to determine the type and amount of change that has taken place. Reanalyze occupational performance, review targeted outcomes, and identify the next action plan to continue or discontinue the OT services.
The review of targeted outcomes is an essential component of the re-evaluation process in occupational therapy. It involves assessing the client's progress toward the established goals and determining the interventions' effectiveness. By objectively measuring the client's functional abilities and comparing the results with baseline measurements, the occupational therapist can determine whether the goals have been achieved, partially achieved, or not achieved. This information is analyzed, and the therapist utilizes their clinical judgment to interpret the outcomes in the context of the client's overall well-being and occupational performance. Through a client-centered discussion, the therapist collaborates with the client to review the outcomes, provide feedback, address concerns, and make any necessary adjustments to the goals or intervention strategies.
The process of deciding whether to continue or discontinue occupational therapy (OT) services involves a thorough evaluation and analysis of the client's progress, goals, and functional needs. The occupational therapist assesses the client's current level of functioning, reviews the effectiveness of the interventions provided, and considers the client's goals and desired outcomes. Based on this comprehensive assessment, the therapist makes an informed decision about whether to continue with the therapy services, modify the treatment plan, or determine that the client has achieved their goals and no longer requires further OT services. This decision is made collaboratively with the client, ensuring that the services align with their needs and best support their ongoing occupational performance and well-being.
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