OCCUPATIONAL THERAPY PROCESS:
EVALUATION AND INTERVENTION IN
PHYSICAL DYSFUNCTION
Topic Objectives
Identify
and describe the major stages in
the occupational therapy process
When a client begins to receive OT services
in a hospital, nursing home, or outpatient
clinic, the treating therapists follow a series
of stages or steps. The Guide to
Occupational Therapy Practice describes
the steps in OT services that are client
centered, effective, and reimbursed:
1. Referral: The physician or another legally
qualified professional requests OT services
for the client. The initial referral may be oral,
but a written record is also necessary. In
most instances, a written referral from a
physician is required for reimbursement
from a third-party payer.
2. Screening: The occupational therapist
obtains data to determine the need for
evaluation and intervention.
The occupational therapist performs a
brief, general assessment to determine
whether OT services would benefit the
client.
[Link]/evaluation: The OT team
attempts to discover the nature of the
client’s problems or to evaluate a specific
area of concern listed by a physician,
parent, or other caregiver in the referral.
The two major parts of evaluation are the
occupational profile and an analysis of
occupational performance.
The occupational therapist analyzes the
evaluation data to identify the client’s
specific strengths and deficits.
4.
Treatment planning or intervention
planning: A plan that will guide actions is
developed in collaboration with the client
(and the client’s caregivers, as
appropriate).
Considering research evidence of
effective treatment principles and
methods, the occupational therapist
develops the initial treatment plan based
on selected theories and intervention
approaches.
[Link] implementation or
intervention:
Intervention is the process of ongoing
therapeutic activities that will influence and
support client occupational performance.
Interventions are directed toward identified
outcomes or goals developed in the
intervention plan.
The client’s response to the intervention is
monitored and documented on a regular
basis, as determined by the clinical facility.
[Link]:
Reevaluation of a client is the process of
evaluating the client’s progress toward
the goals of the treatment plan and
modifying the treatment plan and goals
as needed.
Measurement of the outcomes of
treatment is critical in showing the
effectiveness of the therapy intervention.
The treatment plan may be modified or
continue toward the set plan based on
the reevaluation results.
7. Discharge planning:
The OT team may provide
recommendations for further interventions
at such time as a client is discharged from
a health care facility. Additional OT services
may be necessary as a result of the client’s
change in functional status, living situation,
workplace, caregiver, technology,
development, personal interest, or age.
Working with the client, the client’s family,
and the treatment team, the occupational
therapist and assist