Occupational Therapy Evaluation Considerations

Following a physician referral, an occupational therapist will evaluate first the client's ability to perform in a variety of areas. These areas of occupation include activities of daily living (ADLS) (such as dressing, bathing, sexual activity), instrumental activities of daily living (IADLS) (such as caring for others, health management, meal preparation), sleep and rest, education, work, leisure, play, and social participation (The American Occupational Therapy Association 2008b). As the occupational therapist assesses the client's functional

Physician Referral for Occupational Therapy

Department of Occupational Therapy Physician Referral for Treatment

Client Name: _ Diagnosis:_

Date of Injury/Date of Surgery; _ Precautions:_

If you prefer the therapist to exercise greater clinical reasoning in treating your client, you may select only 'Evaluate & Treaf. The therapist will then choose the intervention options most suitable for the client.

(1 Evaluate & Treat

□ Evaluation Only

□ Continue OT Treatment

Prescribed Treatment

□ Therapeutic Activity

□ Therapeutic Exercise

□ Neuromuscular Re-education

G Wound /Scar Management

□ Work Simplification

□ Ergonomie Evaluation

□ Functional Capaeity Evaluation

□ Work Conclitioning

□ Myo fa sciai Release

□ Home Safety Evaluation

Job Analysis Relaxation Education Deep Tissue Massage Stress Management/ Coping

Energy Conservation Joint Protection Education


Resting Hand Splint Wrist Cock-Up Splint Thumb Spica Splint CMC Splint Long Arm Splint Zipper Splint Elbow Splint Finger Splint

□ Physical Agent Modalities PRN

□ Physical Agent Modalities as Directed

Additional Instructions:_

Ultrasound Fluidotherapy Light Therapy

Transcutaneous Electrical Stimulation The rmotlierapy

Iontophoresis w/ Dexamethasone

Neuromuscular Electrical \ Stimulation Laser Therapy Phonophoresis


include a prescription for that medication.

If you choose an intervention that includes a medication, also

Physician Signature Date

Figure 15.1 Physician referral for occupational therapy.

ability, he/she further evaluates a multitude of factors including the client's neuromuscu-loskeletal, movement, sensory-perceptual, emotional regulation, communication and social, pain, cognitive, cardiovascular, respiratory, skin, and related structures function using objective and subjective assessments (The American Occupational Therapy Association 2008b). Table 15.2 provides a summary of assessment tools commonly used by occupational therapists. Throughout the assessment process, the occupational therapist seeks to understand the client's values, beliefs, culture, home and work environment, roles, habits, and routines to

Table 15.2 Examples of standardized and non-standardized assessments of pain and function used in occupational therapy.

Assessment category

Assessment tool



• Barthel Index of ADLa

Measure clients' functional abilities; a number

• Canadian Occupational Performance

assessments also include pain assessment subtests;


occupational profile provides a summary of the clients

• Disability of the Arm, Shoulder, and Hand

occupational history

(DASH )c

• Functional Independence Measured,e

• Occupational Profilef


• Numeric or visual analogue scales

Describe the uni- or multidimensional subjective and

• McGill Pain Questionnaireg

emotional experience of pain and provides a description

• Pain Drawing Instrumenth

of the quality and intensity of pain; also provides

• Pain Patient Profile (P-3(R))i

localization of pain experience

Ergonomic, work

• Ergo Science Physical Work

Provide work performance and ergonomic assessments

and/or functional

Performance Evaluation (PWPE)

of the clients' work, home, and/or leisure environments

capacity evaluations

• Isernhagen Work Systems Functional

to ascertain areas of needed modification for symptom

Capacity Evaluationk,l

reduction and/or prevention

• Joule 3.0 FCE System by Valparm


• Stress Profilen

Assess clients' coping behaviors as related to stress


• Perceived Stress Questionnaireo

management and coping

• Rhode Island Stress and Coping

Inventory (RISCI)p

aCollin and Wade (1988), bCarswell et al. (2004), cHudaket al. (1996), dHamilton et al. (1987), eGosman-Hedstrom and Svensson (2000), fThe American Occupational Therapy Association (2008), gMelzack (1975), hMargolis et al. (1986), iPearson Education, Inc. (2009), jLechner et al. (1994), kIsernhagen et al. (1999), lReneman et al. (2004), mValpar International Corporation (2009), nNowack (2009), oFliege et al. (2005), pFava et al. (1998).

design a client-centered treatment plan (The American Occupational Therapy Association 2008b).

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