What to Expect from an OT Assessment

Thursday, October 26, 2017

So you’ve been referred for OT… what happens next?

by Christine Creelman, OT in Kingston, Ontario

Following an injury or an accident, there are lots of things that can cause people stress – recovery time, being off work, physical and emotional symptoms – what to expect from an occupational therapy assessment shouldn’t be one of them.

How I prepare for an assessment:

When I get a new client, I always give them a call to introduce myself and set up a date for the assessment. I then review any medical documentation or other information I’ve received so that I can get to know their background. But if there isn’t any medical history, it’s no problem, the client and I can discuss it in our session.

Based on what I know about the client, I gather together the assessment tools that will help identify areas of difficulty and strength.

What to expect from an in-home assessment:

Initial in-home assessments are roughly three hours and provide a general overview of a client’s functioning at home, in the community, and at work. I look at a person’s ability to engage in self-care, productivity, and leisure and how it has been affected by their injuries.

As an OT, I use the Canadian Model of Occupational Performance and Engagement to guide the assessment. During my assessment, I look at the person, their occupation, and their environment, and how these areas interact and overlap with one another.

A client can expect in-depth interviewing, questionnaires, and standardized assessments. I also assess the client’s cognition, mood, psychosocial symptoms, and physical abilities, like balance, range of motion, and functional movements. I look at how all of these areas influence someone’s ability to go about their day-to-day routine.

Based on the assessment, I develop goals with the client to help them re-engage in important areas of their life. These goals direct later OT treatment.

I also make recommendations to help a client function better, these may include devices and equipment, like a bath seat or lightweight vacuum. Recommendations can also be made to other therapists, like physiotherapists, psychologists, or support from a rehabilitation assistant or personal support worker.

What to expect from follow-up sessions:

Follow-up sessions are usually shorter than the initial assessment. They look different for every client, since everyone will have their own difficulties, challenges, and goals. The care that I provide as an OT is client-centered. So in follow-up sessions, we work together on the goals that were identified during the initial assessment.

This means that there is no set picture for what a follow-up session looks like. For some it could be exploring and trialing assistive devices. For others, it could be learning mindfulness and sleep hygiene techniques to help get a better night’s sleep. And for others still, sessions may include a walk through a neighbourhood, a trip to a coffee shop, or a workplace visit. OTs work with the client, with their needs in mind, so treatment is varied.

As we work together, goals can evolve and adapt, which changes the focus of our sessions together. The best part for my clients, but also for me, is when I can help someone reach their goals and accomplish things they weren’t sure were possible.

To make a referral, please click here. To learn more about Christine, please click here.