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Katie Koplow PRT 3360 Assessment and Documentation November 11, 2013 Assessment Protocol Review Assessment Protocol:

- Specialist is responsible for initial preparation before beginning to administer a client assessment - Review standardized assessment protocol - Adhere to assessment protocol so clients are places in therapeutic programs that will meet their needs * Deviations are likely to result in flawed results, causing errors in program placement and inability to produce and document client outcomes.

Preparation: Record Review: Review and understand the chart. Determine the nature of the clients problems and what you are able to help with that is within the scope of practice of a Recreational Therapist. Standardized Assessment: Comprehensive Evaluation in Recreational Therapy-Psych/Behavioral, Revised Organize a time where you observe a client in a group activity. There is no administration time separate from observing a group activity. Provide supplies for activity that client will be participating in during a group setting. One CERT- Psych/R form for each client being evaluated is needed The professional using the CERT- Psych/R should have adequate and relevant training to score and interpret the clients measured functional level. Interview: Organize appointment with client. Set up a comfortable environment; keep in account information you learned from diagnostic protocol that might affect client (ex: quiet, private location, minimal distractions, proper lighting, furniture arrangements). Know how to best communicate with client and meet their specific needs to ensure a successful interview session. Be aware of clients background and be considerate when preparing questions. Know clients skill level and language ability. Be prepared to take notes. Have paper, colored pencils, and sticks for matching game if using them during your interview.

Administration: Standardized Assessment: The purpose of this is to identify, define, and evaluate behaviors relevant to a persons ability to successfully integrate into society using his/her social skills. Document clients interactions after observation session, measure changes that may be a result of medications, identify change over a period of time. Interview: -When working with children a seated interview might not be the most effective. Organize an activity so you and they client can be doing something while you interview them. Our activity will be drawing a picture of the client doing something they enjoy. Warm up: Introduce self and purpose of interview Be aware of tone of voice Demonstrate interest in client and give them full and undivided attention Be aware of clients emotions and feelings and how they are reacting to your questions Be aware of clients posture, speech and breathing Keep clients records in mind when asking the client to do something Be sure to keep clients safety and health concerns a major priority Ask if client is allergic to bees or has other allergies if doing outdoor activities and not on chart Dont ask questions if the information can be found on the documented records * See attached paper for specific interview questions

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Closing:

Offer to answer clients questions Explain how the information will be used Summarize the interview * Be prepare if client gets fatigued or frustrated, have an alternative way of interviewing Scoring: Standardized Assessment: Scoring takes approximately five minutes per client to score after the therapist observes the client in a group activity. CERT- Psych/R provides a useful measure for determining the success of interventions. Even a one-point change is important. The target score for normal functional should be an overall score of zero to three points. Analysis and Interpretation: Review Record Chart, all interview questions and the results from the Comprehensive Evaluation in Recreational Therapy-Psych/Behavioral, Revised. Create goals and objectives based on the results from assessment

Place client into interventions that fit their needs and will help meet goals, objectives and desired outcomes and align with the assessment of their five domains. Reporting: Write up results on the record chart. Develop goals and objectives based on analysis and interpretation of assessment. Share results during team meeting. Katherine Koplow, TRS, CTRS November 13, 2013