THE OCCUPATIONAL TREATMENT PLANNING PROCESS PART 1

DATA GATHERING

By : Catherine A. Trombly

The occupational therapy treatment program is based on information concerning the present and predicted level of the patient’s functioning in his occupational performance tasks. Information sought should include that specified in the uniform occupational therapy evaluation checklist. It is important to verify the consistency of data by obtaining multiple indicators of function. Data can be obtained from the following sources, keeping in mind that “all evaluation methods shall be appropriate to the client’s age, education, cultural and ethnic background, medical status, and functional ability”.

1.      The medical record should yield demographic information concerning the person’s diagnosis, date of onset, medical surgical histories, precautions, medications, age, pertinent social and education/vocational history, and discharge plan, as well as reports of he nursing staff about the disabled person’s daily physical and psychological functioning.

2.      Observation of the disabled person as he attempts to perform functional activities will allow the therapist to determine the person’s present functionallevel as well as his sense of safety and judgement. This observation will also give the therapist a clue as to what is limiting the patient’s functional performance so that appropriate evaluations may be selected to evaluate the sensorimotor limitations more objectively. 

3.      Measurement of the disabled person’s performance to determine baseline performance. The therapist,having observed the patient and knowing the implications of the diagnosis, makes an assessment plan based on a judgment about which capabilities to evaluate and measurement procedures to use to elicit the necessary information regarding the strenghts and limitations of the person. The assessment plan may be modified before the patient is actually seen based on information from records or staff about the patient’s physical and psychological status.

4.      Interview of the disabled person should yield knowledge of his goals, feeling, readiness to participate in or to take responsibility for treatment, expectations for therapy, cognitive abilities such as memory, ability to sequence and organize information, orientation to time, place, and person, comprehension of directions, his perception of what he can do for himself and his interest.

5.      Reports of other professionals who are simultaneously gathering data in regard to the person relative to their particular service should be available from the medical record, be reported at team conferences, or be shared in other less formal ways. This reports will influence the development of the occupational therapy treatment plan.

6.      Interview of family members should result in gaining knowledge of their goals for the disabled family member and their views about how the disability has affected the person, as well as how it has affected each of them and the family unit. Brain injury may cause changes in personality characteristics. The family is the source of information about the patient’s premorbid personality.

7.      It may be necessary for the therapist to read resource material regarding the classical symptoms, course, and prognosis of the person’s disease(s) or to review the precautions and effects of the patient’s medication before planning treatment.