treatment planning process

• ADL
• IADL
• education
• work
• rest and sleep
• play
• leisure
• social participation

gather information

interpret data and indentify problems

set goals and priorities

formulate treatment/intervention plan

treat the client-intervention

reasses/re-evaluateto determine progress

• occupational profile
• medical records/student records
• interview the client/parent/family
• observation of client/patient
• reports from other professionals
• resource materials

• summary of information that describes the client's:
• occupational history and experiences

patterns of daily living

interests

values

• needs
• using a client-centered approach the OT practitioner gathers information to understand what is improtqant and meaning ful to the client

what the client wants and needs to do

interests that may assist in identifying strengths and limitations

client's desired goals and outcomes

• diagnosis/classification
• medical-surgical history
• precautions
• m,edications
• age-sex
• social/vocational history
• D/C plan

• knowledge of illness
• goals-expectations of therapy
• feelings
• motivation
• cognitive abilitiesorientation t time/place/person
• perceptio of what they can do for self

• observe as they perform functional activities
• functional level
• safety
• judgment

• nursing
• physical theraply
• physician
• speech therapy
• social services
• any other services working with the client

• references
• books (text books)
• on-line sources
• classical signs and symptoms
• prognosis
• precautions
• effects of medications

• primary responsibility of the OTR
• profile strengths and weaknesses
• analysis of performance(this is what ota's work from)

formulated from the problem list you have compiled in collaboration with the client/patient.

Goals-Long term goals(LTG)

Objectives-short term goals(STG)

• Goals and objectives must be:
• realistic to the patient/client
• able to be achieved in a "reasonable" amount of time
• objective

to return to an independent living situation, pt.

while performing a stand pivor transfer, pt. will reach for bed or wheelchair before sitting with no verbal cues within 1 week

daily goals that are met while progressing towar5ds the discharge goal

you may have several STG's for each LTG

will transfer independently and safely bed 5 wheelchair while wearing an orthotic foot support within 2 weeks.

goals and objectives need to be modified as the client's progress is observed.

goals and objectives should bne written to reflect your priority

what needs to be done first!!

• you will choose:
• the activity
• the set-up
• the directions to be used
• the role of the therapist in the activity
• the expected outcome

Professional judgement must be used when planning treatment.

treatment must be appropriate

• treatment must be safe
• OT changes LTG
• OTA changes STG

• EX:
• 1. approach-NTD, Biomechanical-theories
• 2. principles-what I can do
• 3. Methods-my way to do things
• 4. decide what to do and how to do it

go back to interpret date and indentify problems

• look at the performance of the client
• look at the effectiveness of the activity
• consider the strength and weaknesses of the client

on going

reassesment is done every time you see the client

allows you to adjust the goals and the treatment activities

behavior objectives=STG

a specific statement about a positive change in a skill which is expected occur within a short period of time

all behavioral objectives MUST be OBSERVABLE and MEASURABLE!!!!!

defines the ACTION

an observable performance or action

• need to use specific verbs
• to complete
• to define
• to recite
• to operate
• to name
• to count

• words not to use-non specific
• to know
• to learn
• to improve
• to understand
• to comprehend
• to do

the physical conditions under which the behavior will occur

• EX:
• given a simlulated patient, the student will write a case history
• the client will prepare a dinner in the microwave
• the child will stack 5 one inch cubes using his right hand.

performance standard

the minimum level of performance that will be accepted as evidence that the objective/behavior has been achieved

usually expressed innumerical terms.

• ways to express minimum level of performance
• how much?
• how often?
• how much of the time?( 3 out of 5 times)
• how long?
• how many?
• how well
• independtly-100%
• when? (does he need assistance)