SOAP
True or False: Caregiver/family communication regarding the client belongs in the S section of a note.
True
TOP-DOWN or BOTTOM-UP: The focus is on the client’s goals and report of limitations and is used in community-based or home health settings
Top-down approach
A brief general assessment conducted by an OT or COTA
Screening
What are the 4 components of goals?
1. Occupation-based functional outcome
[with input from client] (i.e., complete UB dressing)
2. Statement of terminal behavior
(i.e., in order to increase ADL independence)
3. Conditions
(i.e., with mod VCs, with max A, with A/E as needed)
4. Criterion
(i.e., within 3 weeks)
Who provides supportive services, but no skilled OT services?
OT aide
______ is the HEART of your note!
Assessment
TOP-DOWN or BOTTOM-UP: The focus is on body structure and function deficits, the plan compensates for impairments, and it's used in medical-model environments
Bottom-up approach
The goal of the evaluation is to complete an occupational profile and an analysis of occupational performance. What are the 3 components of the occupational profile (per Dr. Wrights ppt)?
1. Occupational history
2. Patterns of daily living
3. Interests and needs
Client will demonstrate ability to independently vacuum 1 room of home, with 0x loss of balance and initiation of energy conservation techniques as needed by 10/29/23.
Identify the criterion.
by 10/29/23
Identify what each letter stands for in the acronym COAST.
C - client
O- occupation
A - assistance level
S - specific
T - time
What section would you place information about a client's functional limitations?
A- assessment
What intervention approach is used if the patient’s previous abilities cannot be restored, focuses on the patient’s remaining abilities, and aims to improve function by compensating for deficits in performance components?
progressive change of process, tools, materials, or environment to gradually increase or decrease performance demands so that the person can develop, improve, or restore a level of competence in an area of occupation
grading
Which of the components of goal writing requires input from the client?
occupation-based functional outcome
What is the training of a single rehab worker to provide services that would ordinarily be rendered by several different professions?
cross-training
(OT, PT, & SLP have overlapping duties)
An objective must be _____, ______, & _______.
measurable, quantifiable, observable
What intervention approach is targeted towards improving performance components (with the assumption that these improvements will lead to enhanced occupational performance)?
Remediation
temporary or permanent use of assistive devices/adaptive equipment, alternative techniques, or environmental changes that allow someone to resume or continue participation in an area of occupation
adapting
Within 1 year, client will complete simple puzzles independently (with minimal assistance) for increased visuomotor and spatial relationship skills.
Identify what component of the goal is in parentheses.
conditions
List 3 tasks/responsibilities an OT aide may have?
1. Transporting clients
2. Setting up equipment
3. Preparing supplies
4. Performing simple and routine client services for which he/she has been trained
In which section would you place the following statement?
Client’s ability to recognize stressors shows good potential to change self-destructive coping strategies
A - Assessment
The ppt discussed some adaptations to compensate for an individual's deficits. List 3 examples of adaptations.
the possibilities are endless :)
1. Using velcro to replace shoelaces
2. Wearing noise-cancelling headphones to filter out auditory stimuli
3. Changing the lighting to decrease overstimulation
4. Using a timer for improved attention to task and task completion
5. Using a long-handled sponge during bathing
6. Adjusting the height of a table to improve posture
7. Labeling drawers and items for improved cognitive deficits, etc.
What are three ways we can modify an activity to grade it?
1. task (sequence, duration, position of materials, weight of materials, etc.)
2. personal approach (position, interpersonal contact, etc.)
3. environment/setting (lighting, distractions, temp.)
Within 1 year, client will complete simple puzzles independently with minimal assist for increased visuomotor and spatial relationship skills.
Identify the statement of terminal behavior.
for increased visuomotor and spatial relationship skills
List the FIM scores and their corresponding assistance levels.
•Independent (7)
•Modified Independent (6)
•Supervision (5)
•Set-up (5)
•Stand-by Assistance (5)
•Contact-Guard Assistance (4)
•Minimal Assistance (4)
•Moderate Assistance (3)
•Maximal Assistance (2)
•Total Dependent + (1)
•Total Dependent