Evaluations/ Assessments
This stage in the evaluation process involves a comprehensive chart review and administration of measurement tools
Initial evaluation
This portion of the Evaluation/Assessment process is where you review previous reports to educate yourself on current levels, and ask open ended questions to gain a fuller understanding
Interview
Intervention directed at the person that focuses on posture, mobility, coordination, strength, effort, and energy
Motor Skills
Process whereby steps of a task are taught in the order they occur
Forward chaining
These are used to record the progress of the intervention process and may be written on a daily, weekly, or monthly basis depending on the setting
Progress notes
This type of assessment has no specified administration rules, content, scoring procedure, or testing environment and the data cannot be compared across individuals
Non-standardized
These can be site specific and provide a list of what to observe and how to record the observations. These typically include a comments section
Checklists
The mental body function where your brain fills in the missing pieces to make sense of what you are seeing
Visual closure
Frequently used in pediatric OT, this is a type of teaching where the therapist uses physical contact to guide the child in task completion
Hand over hand assistance
Another name for “objectives” as related to outcome development in an intervention plan
Short term goals
In this assessment category, the focus is on the same areas as initial evaluation and is done at time intervals or when a change of status occurs
Re-evaluation
Type of observation that allows for minimal-to-no interaction
Distant
The visual discrimination function where the form is the same regardless of size, position or background
Form constancy
This type of teaching principle is used when verbal processing is weaker, the child speaks a different language, or is hearing impaired
Written/Pictorial
The part of a SOAP note where you present the facts and areas that were addressed in the OT session
Objective
Examples of this type of assessment are the Peabody, VMI, and BOT-2
Standardized
Standardized assessments have specified administration rules and scoring procedures and are based on established ______ and ______
Norms and Criteria
This spatial perception function is especially useful for community mobility
Topographical Orientation
Teaching technique whereby a child watches the initial steps but completes the last step
Backward chaining
These two things must always be included at the conclusion of a SOAP note
Therapist’s signature and title
Term used to describe the point where a COTA has a working knowledge of the language and procedure of the assessment and has the ability to obtain the same result in an assessment that the OT would obtain
Service competency
Type of observation that allows for interaction and adjustment by therapist to elicit responses
Active participation
Intervention where adaptations are made to the way in which an activity is done; may be simple or complex
Intervention directed at the task
Knowing your best learning style and consciously applying it. This is perfected as a child matures and generally will emerge in elementary school.
Metacognition
This type of note contains all the same information present in a SOAP note, but presented in paragraph form
Narrative note