NBCOT-CH.1-The Process of Occupational Therapy – Flashcards

-The OT process is comprised of three main aspects of service delivery: evaluation, intervention and outcomes -This process is client-centered,, interactive and dynamic

-The basic request for occupational therapy services. This may also be termed an order or a consultation -Sources include the individual, family or caregivers, physicians, social workers, physical therapists, nurse practitioner, allied health professionals, teachers, administrators, insurance companies, employers, state and local/public and private agencies -The content and form of a referral/order varies among program types and practice areas and can range from highly specific (eg. a resting hand splint) to the very general (eg. evaluate for developmental delays) -While anyone can refer themselves or others to occupational therapy services, the ability of the occupational therapy to act upon the referral is determined by the state licensure laws and/or third party reimbursers

-The acquisition of information to determine the need for an in depth evaluation and to obtain a preliminary understanding of the individual's needs, limitations, assests, and resources -Screening procedures are usually brief and easy to administer since they must be applied to a large number of individuals (ie. all persons who receive an OT referral need to be screened to determine the appropriateness of the referral) -Screening tools measure broad performance abilities and include chart/medical record review, checklists, structured observations, and/or brief interviews with the individual, family, and/or caregivers -The outcome of the screening will determine the client factors, areas of occupation, performance skills, patterns, and/or contexts that require further evaluation

-The comprehensive process of obtaining and interpreting the data necessary to understand the individual, system or situation -If the individual and the OT do not share a common language, an interpreter must be used to ensure the validity of the information obtained and that no cultural or religious norms are violated that may compromise the therapeutic process -Obtain a history of the individual's past level of functional performance -Select an appropriate standardized or nonstandardized evaluation tool -Determine which assessment will attain information essential for setting goals and planning intervention -Administer the assessment according to recommended guidelines, administration protocols, and/or standardized procedures (observe standard precautions) -Score or rate assessment results according to published guidelines or standardized procedures -Interpret the assessment results in relation to uniform terminology, the practice framework, and/or a specific frame of reference: 1) integrate referral, screening, and diagnostic information and data gathered from assessment 2) relate all information to functional abilities and disabilities relevant to person's roles and environmental contexts 3) use caution when interpreting information based on self report or a highly structured assessment as results may not reflect performance in natural contexts 4) identify functional deficits in occupational performance areas relevant to the individual 5) in school/educational settings, assessment information must be related to the multiple aspects of educational performance (academic, mobility, psychosocial, behavioral, self care) -Collaborate with the individual, family, caregivers and other team members to obtain a broader picture of the person's situation and to put the OT assessment results into a larger context ( in school/educational settings, medically necessary OT must be separated from educational relevant OT; referrals to after school, home care, and/or community based OT services are indicated for non-educational OT) -Prioritize identified problems in collaboration with the individual to develop intervention plan -Document and communicate the evaluation findings to relevant parties (ie. consumer, team members, and third party payers) -Refer to other professionals or specialists within the profession, as needed, for further evaluation

-Individual's baseline functional level, major concerns, and pressing needs as determined through the screening process -The environmental context in which the assessment will be conducted (the length of stay of the setting influences comprehensiveness of evaluation; the primary focus of the setting [eg. prevocational versus self management]; legislative guidelines and restrictions [eg. in a school setting, assessments must focus on areas related to the child's educational needs]; the facility's resources of space, equipment and supplies) -The environmental context of the individual's current and expected environment (sociocultural aspects including roles, values, norms, supports [for example, in some cultures home management is only considered a valued role for females, so there is no need to do a home management evaluation for a male of this cultural background]; physical environment characteristics. [for example, it would be essential to measure functional mobility endurance for a person who lives in a third floor walk-up apartment]) -The temporal context of the individual and his/her disability (person's chronological and developmental age; anticipated duration of disability [eg. short-term, long-term, permanent]; recent occurrence of illness or exacerbation of a long-standing, chronic condition; stage of illness [eg. acute stage versus terminal stage]) -The evaluation tool 's compatibility with frame of reference selected to guide intervention planning -Consider ethical concerns and potential ethical conflicts

-Handwashing: 1) wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn 2) wash hands immediately after removing gloves, between patient contacts and when otherwise indicated to reduce transmission of microorganisms 3) wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites 4) use plain (nonantimicrobial) soap for routine handwashing 5) an antimicrobial agent or waterless antiseptic agent may be used for specific circumstances (hyperendemic infections) as defined by Infection Control -Gloves: 1) wear gloves (clean, unsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items; put on clean gloves just before touching mucous membranes and nonintact skin 2) change gloves between tasks and procedures on the same patient after contact with materials that may contain high concentrations of microorganisms 3) remove gloves promptly after use, before touching uncontaminated items and environmental surfaces, and before going on to another patient; wash hands immediately after glove removal to avoid transfer of microorganisms to other patients or environments -Mask and eye protection or face shield: wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions -Gown: 1) wear a gown (a clean, unsterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions 2) select a gown that is appropriate for the activity and the amount of fluid likely to be encountered 3) remove a soiled gown as soon as possible and wash hands to avoid transfer of microorganisms to other patients or environments -Patient-care equipment: 1) handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membranes exposures, contamination of clothing, and transfer of microorganisms to other patients or environments 2) ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately 3) ensure that single-use items are discarded properly -Environmental control: follow hospital procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces -Linen: handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing, and avoids transfer of microorganisms to other patients or environments -Occupational health and bloodborne pathogens: 1) prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures, when cleaning used instruments; and when disposing of used needles 2) never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of a needle toward any part of the body; rather, use either a one-handed "scoop" technique or a mechanical device designed for holding the needle sheath 3) do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand 4) place used disposable syringes and needles, scalpel blades, or other sharp items in appropriate puncture-resistant container for transport to the reprocessing area 5) use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation -Patient placement: 1) use a private room for a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control 2) consult Infection Control if a private room is not available

-Airborne precautions: in addition to Standard Precautions, use Airborne Precautions, or the equivalent, for patients known or suspected to be infected with serious illness transmitted by airborne droplet nuclei (small-particle residue) that remain suspended in the air and that can be dispersed widely by air currents within a room or over a long distance (for example, Mycobaterium tuberculosis, measles virus, chickenpox virus): 1) respiratory isolation room 2) wear respiratory protection (mask) when entering room 3) limit movement and transport of patient to essential purposes only. Mask patient when transporting out of area -Droplet precautions: in addition to Standard Precautions, use Droplet Precautions, or the equivalent, for patients known or suspected to be infected with serious illness microorganisms transmitted by large particle droplets that can be generated by the patient during coughing, sneezing, talking or the performance of procedures (for example, mumps, rubella, pertussis, influenza) 1) isolation room 2) wear respiratory protection (mask) when entering room 3) limit movement and transport of patient to essential purposes only. Mask patient when transporting out of area -Contact precautions: in addition to Standard Precautions, use Contact Precautions, or the equivalent, for specified patients known or suspected to be infected or colonized with serious illness transmitted by direct patient contact (hand or skin-to-skin contact) or contact with items in patient environment: 1) isolation room 2) wear gloves when entering room; change gloves after having contact with infective material; remove gloves before leaving patient's room; wash hands immediately with an antimicrobial agent or waterless antiseptic agent. After glove removal and handwashing, ensure that hands do not touch contaminated environmental items 3) wear a gown when entering room if you anticipate your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent or has diarrhea, ileostomy, colostomy, or wound drainage not contained by dressing. Remove gown before leaving patient's room; after gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces 4) single-patient-use equipment 5) limit movement and transport of patient to essential purposes only. Use precautions when transporting patient to minimize risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment

-Standardization: 1) a standardized evaluation is one that is uniform and well-establish 2) it is always the same in content, administration, and scoring 3) characteristics of a standardized instrument - a description of its purpose; an administration and scoring protocol; established norms and validity -The administration protocol: 1) provides instructions on what to do, ensuring all administrations of the assessment are consistent 2) identifies materials needed for the assessment 3) provides exact wording of directions to give to the individual -The scoring protocol: 1) provides ratings and criteria for determining ratings 2) provides norms for the range of ratings for a specific population 3) types of normative data - age; gender; diagnostic groupings 4) norms are used for a comparative analysis of an individual's score (an individual's characteristics must match the characteristics of the population used to establish the norms [eg. you cannot compare a 25 year old's score with norms based on a 10 year old or a 65 year old]; if the client is dissimilar from the "normed" population, interpretations based on these norms would be inaccurate -Validity measures the assessment's accuracy to determine if the tool measures what it was intended to measure -Reliability establishes the consistency and stability of the evaluation

-Measures the assessment's accuracy to determine if the tool measures what it was intended to measure -Face validity establishes how well the assessment instrument appears "on the face of it" to meet its stated purpose (eg. an activity configuration looks like it measures time use) -Content validity establishes that the content included in the evaluation is representative of the content that could be measured (eg. does the content of a role checklist provide an adequate listing roles?) -Criterion validity compares the assessment tool to another one with already established validity -Types of criterion validity: 1) concurrent validity compares the results of two instruments given at about the same time 2) predictive validity compares the degree to which an instrument can predict performance on a future criterion -Criterion validity is reported as a correlation. The higher the correlation, the better the criterion validity

-Establishes the consistency and stability of the evaluation -If reliable, the evaluation measurements/scores are the same from time to time, place to place, and evaluation to evaluation -Inter-rater reliability or inter-observer reliability establishes that different raters using the same assessment tool will achieve the same results -Test-restest reliability establishes that the same results will be obtained when the evaluation is administrated twice by the same administrator -Reliability is scored as either a correlation or a percentage to identify the degree to which the two items agree/relate

-Observation involves visual assessment of an individual, his/her behavior, and environmental contexts -Interviews involve the therapist asking the individual specific questions -Self report requires the individual to disclose personal information in an organized manner eg. through the completion of a questionnaire -Checklists require the use of a predetermined listing of items against which a person's performance is checked to determine the presence or absence of these items -Rating scales require the individual or therapist to rate reaction, performance, or a set criterion according to an established scale -Performance tests involve structured guidelines and/or standardized procedures for engaging the individual in performing an activity and for scoring this activity Norm-referenced assessments produce scores that compare the individual's performance to a set population's performance -Criterion referenced assessments provide scores that compare the individual's performance to a pre-established criteria

-Observation of a person during actual occupational performance is critical -Observation of performance must be done in different contexts and in structured and unstructured situations -Observations of environmental contexts is also important to assess physical and sociocultural supports or barriers -Use of a structured tool (eg. COTE) to note observations can increase reliability -Observations must be ongoing to assess the nuances of performance and subtle changes in function -The therapist must be aware of his/her own sociocultural background, as this is the lens through which he/she observes and it can influence the interpretation of observations (eg. appropriateness of individual's non-verbal behavior) -The therapist's interpretation of his/her observations must be validated by the consumer and/or caregiver

-Establish the purpose of the interview: 1) questions asked and information sought should be consistent with stated purpose 2) interviewee should feel each question is relevant and significant 3) irrelevant, spurious, and/or extraneous should not be asked -Establish rapport with interviewee: 1) initial interview is often the beginning of a long-term therapeutic relationship 2) set an atmosphere of trust by maintaining confidentiality 3) set an atmosphere of respect by being on time, asking pertinent questions, and actively listening -Ask questions in an organized, formalized manner: 1) interviews are not casual conversations 2) a haphazard approach will not obtain information needed to achieve the purpose of the interview 3) numerous assessment tolls are available to guide the interview (eg. COPM, OPHI) -Observe interviewee's non-verbal communications during the interview: 1) what is not said during an interview can be as important as what is said (gaps in information; affect and mood; physical mannerisms; speech patterns and inflections) 2) interpret the congruence or incongruence of non-verbal behaviors with actual verbalizations -Listen before talking: 1) counteracts preconceived views of interviewee 2) prevents premature recommendations -Question and re-question, as needed, to obtain essential information: 1) follow-up questions should be specific 2) open-ended, leading questions facilitate discussion 3) questions that can be answered by yes or no should be avoided -Comment in a limited manner and only when directly related to the stated purpose of the interview: 1) reassuring comments are used to facilitate interviewee's participation 2) specific suggestions or advice should only be given if intervention is part of interview's purpose -Answer personal questions directed to interviewer by interviewee in a direct and honest manner: 1) purposes of personal questions asked by interviewee - to show a general polite interest in interviewer; to move the therapeutic relationship to a closer level; to indirectly introduce a personal concern of his/her own 2) interviewer should immediately re-direct interviewee to purpose of interview and to him/herself after providing a brief, truthful answer -Lead and direct interview to achieve stated purpose -Interpret verbalizations and nonverbal communications to formulate hypotheses about interviewee's situation: 1) plan can include the need for further evaluation and more information 2) the use of an interview to formulate a plan can prevent interviewing just for the sake of interviewing 3) plans for interventions should be developed collaboratively with the individual using a client-centered approach -Maintain confidentiality at all times

-Conduct family/teacher interviews and home/classroom observations: 1) to explore environmental characteristics related to the child's development 2) to identify family supports and community resources 3) to identify cultural values -Consider appropriate developmental levels in selecting assessments, toys, and other evaluation media -Observe symmetries/asymmetries, stability of trunk, pelvis, hips, and shoulders at rest and during movement -Observe transitional movement in and out of prone, supine, side-lying, quadruped, sitting, standing, kneeling, half-kneel, and in various sitting positions such as tailor, long, heel, or side-sitting -Assess the quality of movement in and out of the above positions -Assess fine motor coordination -Consider proper positioning and adaptive equipment, seating, and technology needs -Assess cognition in the context of play and other occupations -Assess psychosocial skills such as the child's coping style, frustration tolerance, and social interaction -Consider visual and auditory status and aides

-Prevention: interventions designed to promote wellness, prevent disabilities and illnesses, and maintain health -Meeting health needs: intervention designed to satisfy inherent, universal human needs. These needs are not automatically met -The change process: interventions designed to achieve behavioral changes and functional outcomes -Management: interventions designed to reduce or minimize disruptive or undesirable behavior that interfere with therapeutic activities or procedures needed to change areas of dysfunction that are the main focus of intervention (eg. an individual becomes excessively anxious during his/her first use of a wheelchair in an environment outside of the hospital. Supportive interventions are needed to decrease anxiety, thereby enabling the person to work on essential community mobility skills) -Maintenance: interventions designed to support and preserve the individual's current functional level (eg. a reminiscence group to maintain the cognitive and social skills of individuals with early to mid-stage Alzheimer's disease)

-Interventions designed to promote wellness, prevent disabilities and illnesses, and maintain health -Primary prevention: the reduction of the incidence or occurrence of a disease or disorder within a population that is currently well or considered to be potentially at risk (eg. parenting skills classes for teen parents to prevent child neglect or abuse): 1) in the AOTA practice framework, primary prevention is termed 'create/promote' and 'health promotion' 2) interventions focus on providing enrichment experiences to enhance a person's occupational performance in their natural contexts -Secondary prevention: the early detection of problems in a population at risk to reduce the duration of a disorder/disease and/or minimize its effects through early detection/diagnosis, early appropriate referral and early/effective intervention (eg. the screening of infants born prematurely for developmental delays and the immediate implementation of intervention for identified delays) -Tertiary prevention: the elimination or reduction of the impact of dysfunction on an individual (eg. the provision of rehabilitation services to maximize community integration) -In the AOTA practice framework, the term 'disability prevention' is used to designate interventions that address the needs of persons with or without disabilities who are considered at risk for problems with their occupational performance: 1) interventions focus on preventing the occurrence or minimizing the effects of barriers to occupational performance

-Interventions designed to satisfy inherent, universal human needs. These needs are not automatically met and they include: -Psychosocial: the need for adequate shelter, food, material goods, sensory stimulation, physical activity and rest (eg. institutionalized orphans confined to cribs require sensorimotor interventions to counter environmental deprivation) -Temporal balance and regularity: the need for a satisfying balance between work/productive activities, leisure/play, and rest (eg. forced leisure due to involuntary unemployment requires intervention to achieve temporal balance) -Safety: the need to be in an environment free from hazards or threats (eg. living in a chaotic, abusive home does not meet this need and interventions are needed to ensure safety) -Love and acceptance: the need to be accepted and loved for one's personal attributes and uniqueness, not for one's accomplishments (eg. the barriers caused by aphasia and ataxia can hinder meeting this need, therefore, supportive interventions are indicated) Group association: the need to feel a connection to others who share similar interests and goals (eg. the stigma and symptoms of mental illness can prevent regular interactions with a group; therefore, interventions to develop social interaction skills and provide community supports are indicated) -Mastery: the need to successfully complete an activity or meet a goal because it is interesting and challenging (eg. deficits in performance components can hinder successful performance and block mastery, therefore intervention to develop performance skills and/or adapt activities are needed) -Esteem: the need to be recognized for one's accomplishments (eg. lack of opportunity to do activities perceived as worthwhile by others requires interventions to facilitate recognized contributions) -Sexual: the need for recognition of one's sexuality and the satisfaction of sexual drives (eg. institutional rules against adult consensual sex prohibit meeting this need and require review and revision) Also, physical impediments to sexuality may require activity adaptations and environmental modifications -Pleasure: the need to do things just for fun (eg. the child on an intensive school and home physical rehabilitation program needs an intervention plan supportive of spontaneous play) -Self actualization: the need to engage in activities just for one's self and for personal satisfaction (eg. the person who writes poetry through an augmentative communication device for the joy of free expression)

-Interventions designed to achieve behavioral changes and functional outcomes -This type of intervention is the most commonly used in OT practice and is the most reimbursable -This process is often the only form of intervention discussed or documented -Most guidelines for intervention planning and intervention implementation relate directly to this process -In the AOTA practice framework, the terms 'establish/restore/remediation/restoration' are used to distinguish interventions that change a person in some manner -Interventions focus on establishing a skill or ability that a person had never developed and/or restoring a skill or ability that the person had lost due to impairment

-Interventions designed to reduce or minimize disruptive or undesirable behavior that interfere with therapeutic activities or procedures needed to change areas of dysfunction that are the main focus of intervention (eg. an individual becomes excessively anxious during his/her first use of a wheelchair in an environment outside of the hospital. Supportive interventions are needed to decrease anxiety, thereby enabling the person to work on essential community mobility skills) -In the AOTA practice framework, the term 'modify/compensation/adaptation' are used to distinguish interventions that alter the context or demands of an activity to reduce distracting features -Compensation and adaptation techniques are also used to alter the context or demands of an activity to support the person's ability to engage in areas of occupation (eg. the provision of cues)

-Interventions designed to support and preserve the individual's current functional level (eg. a reminiscence group to maintain the cognitive and social skills of individuals with early to mid-stage Alzheimer's disease) -No improvement in function is planned due to the chronicity of the disorder or the progression of the disease -A decline in function is prevented, as much and for as long as possible -Maintenance programs include familial, environmental, and social supports and consistent and regularly scheduled follow-ups -While maintenance is not often reimbursed by third-party payers, it is a major type of OT intervention due to the chronic and progressive nature of many disorders with which we work -In the AOTA practice framework, the term 'maintain' is used to designate these interventions

-The formulation of the plan for intervention based upon an analysis of evaluation results according to selected frame(s) of reference -Collaboration with the individual, family, significant others, and/or caregivers is essential to establish a relevant, meaningful plan that will be followed -Prioritization of problem areas to be addressed in interventions: 1) values, interests, and needs of the individual, family, significant others, and caregivers 2) individual's current and expected roles and environmental contexts 3) the treatment setting's characteristics, resources, and limitations (eg. length of stay) 4) the likelihood that the problem will respond to intervention within the given setting (concrete and specific problems are more likely to be effectively resolved than abstract global ones; services must be available within the setting to effectively address the problem; otherwise a referral is indicated) -Formats of written intervention plans can vary from setting to setting -Intervention plan content

-Long term goals (LTGs): the change in activity limitations and participation restriction that will occur, prior to the termination of intervention, in order to achieve the desired functional occupational performance outcome -Short term goals (STGs) or objectives: the component subskills which are to be achieved over shorter time frames, leading to the attainment of the long term goal: 1) STGs must be directly related to the LTG 2) due to the reality of very brief lengths of stay (LOS) in some settings, only STGs may be accomplished prior to the termination of intervention 3) referrals to other settings with longer LOS or home care services may be required for intervention to attain LTGs) -Intervention methods: 1) the meaningful occupations and purposeful activities and their associated tasks, techniques, procedures, and modalities that are used to achieve goals 2) methods of intervention must be clearly related to, and theorectically consistent with, the established goals 3) home programs and/or family caregiver training may be included 4) adaptive/assistive equipment, orthotics,, prosthetics, and/or environmental modifications to meet individual's needs are specified -Duration, frequency, and number and type of intervention sessions planned to attain goals are specified (eg. 10 community mobility groups, meeting for 1 hour, 3 times per week) -Recommendations for additional OT services and referrals, if needed, to other professionals are provided -The design of all intervention plans must actively use clinical reasoning to ensure that each plan's primary focus is on the individual's engagement in occupation and participation in his/her chosen contexts

-Fundamental OT principles are used to guide OT interventions -Overview of OT intervention methods -Purposeful activities and meaningful occupations are used therapeutically -Environmental modifications and adaptations are provided to enhance function -Promotion of engagement in valued occupations is used to foster health and wellness -Adaptive equipment, assistive technology, and orthotic devices are designed, fabricated and applied to faciitate function -Adaptive equipment, assistive technology, orthotics, prosthetic use training are provided to promote independence -Physical agent modalities are used to prepare for, or as an adjunct to, engagement in therapeutic functional activities -Ergonomic principles are applied to the performance of meaningful occupations -Standard precautions are observed (standard precautions are the primary strategy for control of nosocomial infection and are used in the care for all persons) -Transmission-based precautions are used for persons with known or suspected infections of highly transmissible or epidemiologically important pathogens (includes airborne precautions, droplet precautions and contact precautions) -Individual, group or population interventions may be used

-Explanation: people have the potential to improve performance skills, patterns (habits, routines, and rituals), and body functions -Example: a homemaker who has impairments and problems in motor skills resulting from a stroke benefits more from working in the actual occupation of preparing meals in conjunction with exercises to increase her ROM, muscle strength, and coordination as opposed to solely using exercise equipment and objects stimulating the motor actions of the activity

-Explanation: the features of the context and environment may have changed and thus may demand the use of new performance skills and habits for the client to perform successfully -Example: women with developmental delays and psychiatric conditions had a reduced rate of inappropriate behaviors and increased rate of socially appropriate behaviors in a new community living arrangement when given positive reinforcement in perusing everyday occupations

-Explanation: chosen occupations often are a reflection of what people value and enjoy and thus are more likely to be satisfying -Examples: older adults were motivated to resume engagement in occupations because of opportunities to reestablish relationships with others during engagement in valued occupations

-Explanation: values influence occupational choice. When active in occupations, one experiences pleasure and satisfaction, thus generating interests -Example: older adults living within their communities related the three most important activities required for them to remain in their communities as using the telephone, using transportation, and reading; health professionals' list consisted of using the telephone, managing medications and preparing snacks

-Explanation: the client must have the opportunity to develop patterns that include the remediated skill in routine daily tasks -Example: elementary students with learning disabilities and handwriting problems who practiced keyboarding in a training program improved written communication skills for performance at school

-Explanation: corrective feedback regarding performance helps the client modify behavior -Example: a computer system was modified for a person with a head injury to provide an auditory prompt to mark the commencement of each planned activity. "I was just sitting there on the sofa doing something like reading a newspaper, and had completely forgotten the swimming bath, the computer started to bleep; oh, what had I forgotten now?"

-Explanation: success motivates further change and continued use and practice of newly learned performance skills during engagement in occupations -Example: people with severe mental illness develop skills and competence in work and social activities while participating in a supported work setting

-Explanation: interventions designed to eliminate physical and social barriers increase opportunities for social interaction, leading to increased interaction and sense of control in context and environment -Example: children with impaired performance skills used an adapted powered-mobility riding toy, which increased opportunities for participation with other children and adults during the occupation of play

-Explanation: interventions that focus on improving a client's ability to self-direct change in lifestyle choices can lead to a sense of control -Example: people with chronic disorders who participate in community-based group services developed responsibility for their own health by empowerment of the group members

-Explanation: regardless of the presence of impairments, a person may remain active and engaged in healthy occupations -Example: people with fibromyalgia who successfully used activity modification strategies to complete daily activities reported positive quality of life and health

-Explanation: a person's capacity for performance is affected by the status of body structures and functions. Permanent loss of capacity necessitates modification of the context and environment and of activity demands -Example: patients who had hip fractures demonstrated more efficiency and greater satisfaction in recovering performance skills in daily occupations when modified activity procedures were emphasized

-Explanation: discovering identity is related to what a person does and to those people with whom they come in contact during daily occupations and activities -Example: people with injuries to the hand resumed occupations that facilitated resumption of their identity

-Explanation: a person's evaluation of performance in occupations and activities influences perceptions about himself or herself -Example: people recovering from a stroke demonstrated positive views and acceptance of the need for a wheelchair, described opportunities for continuity of previous life activities, maintenance of mobility, and decreased burden on the caregiver

-Explanation: the meaning of occupations refers to the subjective experience one has when engaging in activities -Example: people recovering from a stroke stood longer when performing personally meaningful tasks

-Explanation: performance of valued occupations provides for achievement of personal goals in a variety of roles -Examples: satisfaction through occupations was found when older adults maintained daily routines and engaged in fulfilling occupations. Goldberg, Brintell, and Goberg (2002) found a correlation between engagement in meaningful activities and life satisfaction

-Explanation: people occupy time through engagement in activity -Example: in a study of time use, older people spent most of their time completing activities that were meaningful for them and not necessarily the activities that were necessary for them to remain in the community

Individual: -Learning capacity of the person -Amount of attention and skill required from the occupational therapy practitioner owing to body structure and function impairments -Need for privacy -Need for greater control over the context and environment -Difficulty or complexity of occupation and activity demands, performance skills and performance patterns -Inappropriate or dangerous behavior of the person Group: -Developing interpersonal skills -Engaging in socialization -Receiving feedback from people experiencing similar conditions -Being motivated by peer role models -Learning from other people -Placing one's own condition into perspective -Developing group normative behavior for successful performance in shared occupations (eg. work, study, and leisure groups)

-All activities, toys, and other intervention media must be appropriate to the child's developmental level -Play activities should be the primary occupation intervention -Family education is essential: 1) identify environmental characteristics that facilitate the child's development 2) provide advocacy training to link families to community 3) identify psychosocial factors that promote the child's development 4) teach avoidance of behaviors that may interfere with learning 5) consider and respect the family's cultural background -Provide consultation or direct treatment to facilitate school performance and achieve educational goals -Provide treatment to facilitate sensorimotor, cognitive, and psychosocial development -Fabricate or requisition positioning equipment and technological aides for home and/or school -Ensure the proper visual and auditory aides are used during treatment sessions

-The process of determining whether the individual's occupational performance has improved, declined, or remained the same after interventions -Frequent monitoring of an individual's response to intervention is an integral part of all OT interventions -Effective interventions resulting in the individual's progress require intervention plan modification and an upgrading of goals, as long as there is a reasonable expectation that the individual can improve functional performance -If the individual is not progressing according to plan, different intervention methods, referral(s) to experts in the field or other professions or to another level of care, and/or discharge from intervention may be indicated

-The process for planning for discontinuation of services -Reasons for discharge: 1) the individual's goals have been met 2) the individual has reached a functional plateau 3) the individual does not require skilled services, for maximum benefit has been achieved 4) an exacerbation of an illness or a medical crisis requires a discharge to a higher level of care 5) the person's allotted length of stay in the setting has expired and extension of LOS is not possible -General principles: 1) discharge planning begins with the initial evaluation and is an inherent part of the intervention planning process. All interventions should be planned with consideration of the expected, planned discharge environment 2) collaboration with the individual, family, significant others, caregivers, other professionals on the team, employers, and reimbursers is required for an effective and realistic discharge plan 3) discharge may include transfer to a long-term care setting (eg. skilled nursing or assistive living facility), to an intermediate care facility (eg. halfway house), or to a home setting (a pre-discharge home evaluation must be completed to ensure the individual will be safe and to identify needed home adaptations or supports [eg. bathroom modifications, home health aide]) 4) a well planned discharge facilitates community integration and maintenance of functional gains -Follow-up referrals for other OT intervention and/or other supportive services must be made: 1) home programs - recommendations to the individual, family, significant others, and caregivers on techniques and procedures to maintain and/or improve functional status; training should be provided prior to discharge; information on additional supports should be provided 2) community resources - recommendations and referrals to specific services in the community that can support function (eg. AA, day treatment)

-The established, legitimate means by which the practitioners of a profession achieve the profession's goals and meet society's needs

-Definition: goal-directed pursuits which typically extend over time (they have purpose, value, and meaning to the performer, and involve multiple tasks; they are the ordinary and familiar things that people do every day) -Basic concepts of occupation: -Every individual has multiple occupations that are meaningful (eg. self-care, home management, work and leisure) and needed to function in roles (eg. parent, worker, student, hobbyist) -Humans are innately occupational beings and are driven by an inherent need for mastery, self-actualization, self-identity, competence, and social acceptance -Occupations have social, cultural, physical, and temporal contextual dimensions because they involve activities within specific settings and extend over time -Occupations have symbolic and spiritual dimensions, as individuals infuse individualized meanings into occupations -Occupations are interdependent (eg. one must work to pay for leisure; one must have leisure to sustain and renew oneself for work) -Health is attained when the dynamic balance between occupations and rest is appropriate and meets the needs of the individual -Occupation can be viewed and used as a "means" or a method to change an individual's performance (eg. playing a board game to increase sensorimotor skills) -Occupation can also be viewed and used as an "end" or desired outcome (eg. playing a board game to improve the ability to engage in age-appropriate social play) -Engagement in occupation to support the individual's participation in environment(s) of choice is the overriding desired outcome of OT -Areas of occupation: -Activities of daily living: activities that involve care of self; often called personal activities of daily living (PADL) or basic activities of daily living (BADL) -Instrumental activities of daily living: activities that involve environmental interaction; they are more complex than self-care and can be optional (eg. home maintenance, care of others, and community mobility activities) -Work: all productive activities that contribute services, goods, or commodities to society, whether financially compensated or not (ie. a student or volunteer is working) -Education: activities that involve the student role and participation in an educational environment -Play/leisure: all activities engaged in for pleasure, relaxation, amusement, and/or self-fulfillment -Social participation: activities involving interaction with community, family, and peers/friends

-Doing processes that are directed toward a desired and intended outcome and require energy and thought to engage in and complete -Goal directed tasks and/or behaviors that make up occupations

-Universally, people participate in purposeful activities, although there are personal and sociocultural differences in the manner in which activities are performed (eg. dressing) -Fundamental to the development and acquisition of performance component skills is active participation in purposeful activities (eg. the development of eye-hand coordination through play) -Fundamental to occupational performance areas is the performance of purposeful activities (eg. to work involves completion of multiple tasks) -Purposeful activities are composed of identifiable parts that can be analyzed -Purposeful activities are holistic -Purposeful activities can be manipulated and adapted to be appropriate to, and/or therapeutic for, the individual -Purposeful activities can be graded along many dimensions to meet the needs of an individual -Determination of the individual's differential responses to purposeful activities can provide information for the selection of appropriate activities for use in evaluation and intervention -Verbal and nonverbal communication is facilitated through engagement in purposeful activities -Organization and ability to focus are enhanced because purposeful activities provide concrete structure -Doing is emphasized -Involvement in, and with, the nonhuman environment is enhanced -Purposeful activities can vary on a continuum from conscious to not conscious/unconscious -Purposeful activities vary on a continuum from real to symbolic -Purposeful activities vary on a continuum from simulated in a clinical setting to real in the individual's natural environment

-The breaking down and identification of the component parts of an activity/task -Determination of the abilities needed to effectively perform and successfully complete the activity/task -Determination if the activity/task has therapeutic value

-Specify the exact activity/task to be analyzed (ie. not just "dressing" but "donning a sweatshirt") -Identify and know the procedures, materials, and tools needed to complete the specific activity/task -Analyze the activity/task as it is typically performed under ordinary circumstances -Analyze the activity/task to be certain that all client factors, performance skills and patterns, and activity/task performance components and contexts are considered (select a frame of reference to determine which aspects of the activity/task are to be emphasized in the analysis

-The process of designing an activity for OT evaluation or intervention -Combines information obtained from the activity analysis with assessment information about the individual to ensure that a suitable match is made between the activity requirements and the person's needs and abilities -Effective activity synthesis often requires the adaptation and/or gradation of the selected activity

-Teaching an activity: 1) analyze the nature and sequence of the subtasks within the activity 2) synthesize to determine the best way to present the activity as a learning experience -Determining whether an individual can perform an activity: 1) analyze the performance skill requirements of the activity 2) synthesize by comparing the activity requirements with the individual's functional level -Adapting an activity: 1) evaluate the individual's functional capabilities 2) analyze what parts of the activity can be changed 3) identify what functional aids can be used to allow the individual to successfully perform the activity -Grading an activity: 1) determine what aspects can be changed along a continuum of performance 2) identify the individual's performance skill deficit(s) and/or client factors requiring intervention 3) synthesize to upgrade or downgrade complexity or difficulty level of the activity to meet the needs of the individual

-Definition: the process by which the OT practitioner designs experiences to facilitate the individual's acquisition of the knowledge and skills needed for living

-Learning is influenced by the individual's interests, age, sex, sociocultural factors, and current assets and limitations -Attention to the learning experience and perception of the situation influence learning -The learner's sources of motivation must be identified and used for engagement in learning experiences -Learning goals made by the individual are more likely to be met than goals determined by others -Learning is enhanced when the individual understands the reason for and purpose of the learning activity -Learning is increased when it recognizes the individual's current functional level, and is initiated within the person's capabilities (ie. not too high or too low) -Learning is enhanced when activities and experiences proceed at a rate that is comfortable for the individual -Individuals who actively participate in the learning process learn more, for experiential learning is more effective than didactic learning -Reinforcement and feedback on the individual's behavior and/or task performance are important parts of the learning experience and can be used to support desired behaviors and extinguish undesirable behaviors -Learning can be enhanced through trial and error, shaping, and imitation of models -Frequent repetition and practice in different situations facilitates learning and encourages generalization -Planned movement from simplified wholes to more complex wholes facilitates integration of what is to be learned -Inventive solutions to problems (as well as more useful or typical solutions) should be encouraged -The environment of the learning experience can strongly influence the success of that experience -Individual differences in the way anxiety affects the individual's learning must be considered -Conflicts and frustrations, inevitably present in the learning situation, must be recognized and provisions made for their resolution or accommodation -Continuity between the planned therapeutic learning experiences and the real-life situations for which the individual needs to be prepared facilitates the effective transfer of learning and the generalization of knowledge and skills

-Definition: ways to present information and/or a task to an individual on a one-to-one basis or in a group -Demonstration and performance -Exploration and discovery -Explanation and discussion -Role play -Simulation -Problem solving -Audiovisual aids -Repetition and practice -Behavioral management -Consumer/family/caregiver education

-The OT practitioner performs the task and the individual imitates the OT practitioner's performance -For example, the OT practitioner demonstrates one-handed cooking techniques, and the use of adaptive equipment, and the individual with a unilateral upper extremity amputation imitates therapist's task performance

-A diversity of activities is made available and the individual is permitted to choose any activity and try it without specific instructions or direction -For example, in an expressive arts group, members can select from a diversity of media and create individual works

-A verbal explanation of the task and a discussion of the activity components to either plan an activity or to review what occurred during the activity are provided by the therapist -For example, in a vocational group, the steps for applying for a job are explained and what happened during a job interview is reviewed

-The OT practitioner and/or individual(s) assume roles and act out scenarios to practice behaviors prior to doing the behavior in a real situation -For example, the OT practitioner plays the interviewer and the individual plays the job applicant

-The individual acts out an activity performance using simulated tasks and/or objects -For example, using a driving simulator prior to driving in a car on a roadway

-The process of teaching a person to analyze a situation, define the problem, outline potential solutions, select the solution that appears to be most viable, implement the solution, evaluate the outcome to determine if the problem is resolved, and re-try a new solution, if needed -For example, an individual living in a supportive apartment is having a problem getting his/her roommate to share household tasks

-The use of slides, videos, and/or audio cassettes to teach material with or without the presence of a therapist -For example, an individual with anxiety is provided with relaxation tapes to use at home

-The repetitious engagement in a task to increase accuracy and speed -For example, repeatedly closing the fasteners on clothing to decrease the time needed to get ready for work in the morning

-The identification of behaviors that require development (eg. appropriate social skills) and/or require extinction (eg. hitting people) -The implementation of a structured program to facilitate the desired behavioral change -For example, appropriate social skills are rewarded with praise, whereas aggressive acts lead to a solitary "time out" period

-An organized, systematic approach to formally present information to increase knowledge -The nature of the illness or disease, including etiology, signs and symptoms, functional implications, prognosis, and interventions are explained -The maintenance of roles and occupational performance is emphasized -Methods for the prevention of secondary problems (eg. decubiti), are provided -Community resources and supportive services are explored with appropriate referrals made

-Definition: the complex mental processes the therapist uses when thinking about the individual, the disability and the personal, social, and cultural meanings the individual gives to the disability, the uniqueness of the situation, and him/herself -Value for OTs in practice: 1) improves clinical decision-making by giving therapist tools for self-conscious reflection on their decision 2) improves ability to explain the rationales behind therapists' decisions to consumers, family members. team members, and medical finance agencies (eg. insurers) 3) improves job satisfaction by making therapists more aware of the complexity of their work, the value of their practice

-Procedural reasoning/scientific reasoning: 1) involves identifying OT problems, goal setting, and treatment planning 2) involves implementing treatment strategies via systematic gathering and interpreting of client data 3) the actual technical "doing" of practice 4) the reasoning that is documented the most for reimbursement purposes -Interactive reasoning: 1) deals with how the disability or disease affects the person; focuses on the client as a person 2) involves the therapeutic relationship between the therapist, the individual, and caregivers 3) facilitates effective treatment, as it focuses on the personal meaning of illness and disability which can influence how a person engages in treatment (ie how motivational issues affect client's performance) 4) congruent with the profession's philosophy and heritage of caring -Narrative reasoning: 1) deals with the individual's occupational story and focuses on the process of change needed to reach an imagined future 2) identifies what activities and roles were important to the person prior to illness/injury 3) analyzes what valued activities and roles the individual can perform now 4) explores what valued activities and roles are possible in the future, given the person's disability 5) asks what valued activities and roles the individual would choose as priorities for the future 6) neglects larger practice area issues in which the client/practitioner interaction is occurring (eg. pragmatic constraints imposed by reimbursement, equipment, and/or organizational culture) -Pragmatic reasoning: 1) considers the context in which the OT practitioner's thinking occurs 2) states the mental activities are shaped by the situation (ie. is setting long term or acute?) 3) considers the treatment environment and OT practitioner's values, knowledge, abilities, and experiences 4) focuses on the treatment possibilities within a given treatment setting 5) reframes understanding of the influence of personal and practical constraints on OT practice 6) the most effective OT practitioners are able to negotiate pragmatic contextual issues in favor of quality care -Conditional reasoning: 1) involves an ongoing revision of treatment 2) focuses on current and possible future social contexts 3) represents an integration of interactive, procedural, and pragmatic reasoning in the context of the client's narrative 4) requires multidimensional thinking

-Definition: the practitioner's conscious, planned interaction with the individual, family members, significant others, and/or caregivers (the conscious, planned use of one's personality, unique characteristics, perceptions and insights during the therapeutic process -Purposes of therapeutic use of self: 1) provide reassurance and/or information 2) give advice 3) alleviate anxiety and/or fear 4) obtain needed information 5) improve and maintain function 6) promote growth and development 7) increase coping skills

-Perception of the individuality and uniqueness of each person -Respect for the dignity and rights of each individual regardless of past or present situation or possible future potential -Empathy to enter and share the experiences of an individual while maintaining one's own sense of self -Compassion to be kind and want to alleviate pain and suffering -Humility to recognize one's own limitations -Unconditional positive regard to be non-judgmental and accept, respect, and show concern and liking for each individual as a human being, regardless of presenting behaviors -Honesty to be truthful and straightforward -A relaxed manner to leave other concerns aside and schedule sufficient time to be with the persons so that external issues do not impeded on the relationship -Flexibility to modify behavior to meet the needs of each individual and deal with circumstances as they arise or change -Self-awareness to accurately know one's assets and limitations and to be able to make changes as needed to interact more effectively in therapeutic relationships -Humor to appropriately recognize and/or use what is amusing and comical

-Negative attitudes, fear or hostility towards individuals who are different and/or towards the unknown -Resistance to establishing a rapport due to past rejections and/or fear of future rejection -Communication difficulties: 1) incongruence between verbal and non-verbal communications (when spoken words do not match a person's facial expression, tone of voice, gestures, or postures), resulting in confusion 2) language difficulties - psychiatric symptomatology such as blocking, circumstantiality, flight of ideas, confabulation, grandiosity, articulated delusions, loosening of association, and/or poverty of content can hinder effective communication; cultural, class, educational, and/or regional differences can result in misunderstandings or lack of comprehension between individuals; misinterpretations can occur due to differences in primary language -Dependency that is excessive, and hinders the individual's growth towards interdependence and/or independence -Transference and countertransference: 1) transference is an unconscious response to an individual that is similar to the way one has responded to a significant person (eg. the practitioner is responded to as a parent) 2) countertransference is an unconscious response to transference in which the individual responds in a manner that is expected and desired by the person who has transference towards him/her (eg. the practitioner assumes a parental role towards a client) -Difficulty expressing feelings due to personal reticence or cultural background -Over involvement that results in a loss of objectivity or a fear of involvement that leads to detachment -Difficulty with developing an individual therapeutic style that is a comfortable "fit" so that being a therapist becomes a natural part of one's self

-Develops the ability to use oneself therapeutically -Assists with the common issues and responses -Increases effectiveness in applying therapeutic principles in daily practice

-Group dynamics are the forces which influence the nature of small groups, the interrelationships of their members, the events that typically occur in small groups and ultimately, the outcome(s) of these groups -Group dynamics can be examined according to the group's structure, content, and process

-The stages groups typically go through from their initial beginnings to their termination -Origin phase involves the leader composing the group protocol and planning for the group (eg. size of the group, member characteristics, location of meetings) -Orientation phase involves members learning what the group is about, making a preliminary commitment to the group, and developing initial connections with other members -Intermediate phase involves members developing interpersonal bonds, group norms, and specialized member roles through involvement in goal-directed activities and clarification of group's purpose -Conflict phase involves members challenging the group's structure, purposes, and/or processes, and is characterized by dissension and disagreements among members (unsuccessful resolution of this phase results in dissolution of the group; successful resolution of this phase results in modifications to the group that are acceptable to members, enabling the group to proceed to the next phase of development) -Cohesion phase involves members regrouping after the conflict with a clearer sense of purpose and a reaffirmation of group norms and values, leading to group stability -Maturation phase involve members using their energies and skills to be productive and to achieve group's goals -Termination phase involves dissolution of the group due to lack of engagement or members, inability to resolve conflict, administrative constraints (eg. only 4 sessions allotted for a discharge planning group), goal attainment, or task accomplishment

-Describe the patterns of behavior that are typical within groups -Instrumental roles are functional and assumed to help the group select, plan, and complete the group's tasks (eg. initiator, organizer) -Expressive roles are functional and are assumed to support and maintain the overall group and to meet members' needs (eg. encourager, compromiser) -Individual roles are dysfunctional and contrary to group roles, for they serve an individual purpose and interfere with successful group functioning (eg. aggressor, blocker)

-The standards of behavior and attitudes that are considered appropriate and acceptable to the group -Behavior that falls outside of the group's range of acceptable behavior is considered deviant and is often negatively sanctioned -Norms can be explicit and clearly verbalized (eg. confidentiality is maintained by all group members, aggression is not tolerated) -Norms can be non-explicit and not verbalized (eg. discussion topics that are taboo) -Norms can vary in different groups and can change as a group develops and/or membership changes -Therapeutic norms: 1) encourage self-reflection, self-disclosure, and interaction among members 2) reinforce the value and importance of the group by being on time and well-prepared 3) establish an atmosphere of support and safety 4) maintain confidentiality and respect 5) regard group members as effective agents of change by not placing the group leader in the expert role

-The desired outcomes of the group that are shared by a sufficient number of the group's members -The group's efforts is mostly aimed at attaining these goals -Group goals provide focus for the group and guidelines for group activities and interactions -Group goals are not a compilation of individual member goals. Members may have diverse goals but attainment of the group goal will facilitate personal goal achievement -Benefits of member participation in group goal setting: 1) a match between members' goals and group's goal(s) 2) increased understanding of the requirements for achievement of the goal(s) 3) increased appreciation of each member's contribution to achieving group's desired outcomes

-The process of giving, receiving, and interpreting information through verbal and non-verbal expression -Effective group communication is a prerequisite to, and a requirement for, all group functioning -Effective communication occurs in a group when a member sends a message and the message is interpreted by the other group members receiving the message in the manner that the sender intended -Sending and receiving messages often takes place simultaneously due to the dynamic process of verbal and non-verbal communication -Communication can take many forms, including monologue, criticism, orders, questions and answers, and open give-and-take -Group communication that is adaptive may include clarifying goals and the sharing of ideas, experiences, and feelings -Group communication that is maladaptive may include seeking to control the group by controlling the channels of communication, and avoidance of specific issues or persons

-The degree to which members are committed to a group and the extent of members' liking for the group (eg. the sense of "we-ness") -Factors that contribute to cohesiveness: -Extensive interaction between members -Similarity or complementariness in member characteristics -Perception of relevance of group to individual needs -Members' expectation of goal attainment and successful group outcome -Democratic leadership and member cooperation

-The process of agreeing on a resolution to a problem. The solution may be obtained through different processes -Unanimous decision in which all group members agree -Consensus in which members agree to the majority's decision but retain the right to reconsider their decision -Majority rule in which the majority's decision is accepted with no reevaluation of the decision by members -Compromise in which a combination of different points of view results in a decision that is different from each distinct point of view

-Directive leadership takes place when the OT practitioner is responsible for the planning and structuring of much of what takes place in the group: 1) this style is needed when the members' cognitive, social and verbal skills, as well as engagement, are limited (eg. parallel or project level groups) 2) directive leaders select the activities to be used in the group 3) they provide clear verbal and demonstrated instruction to complete tasks 4) group maintenance roles and feedback is predominately provided by the directive leader 5) the directive leader's goal is task accomplishment -Facilitative leadership occurs when the OT practitioner shares responsibility for the group and the group process with the members: 1) this style is advised when members' skill levels and engagement are moderate (eg. ego-centric cooperative, or cooperative) 2) facilitative leaders collaborate with group members to select the activities to be used in a group 3) members and leaders share instruction throughout the group's process 4) group maintenance roles and feedback are provided by members with the leader facilitating the process 5) facilitative leader's goal is to have members acquire skills through experience -Advisory leadership takes place when the OT practitioner functions as a resource to the members, who set the agenda and structure the group's functioning: 1) this style is assumed when members' skills and engagement are high (eg. mature groups) 2) members select and complete the group's activity with leader's advice, if needed 3) group maintenance roles are independently assumed by group members 4) feedback occurs as a natural part of the group's self-directed process 5) the advisory leader's goal is to have members understand and self-direct the process

-The individual is able to: -Engage willingly in group -Attend to group guidelines/procedures -Actively participate in group process -Benefit from group leadership input -Benefit from group membership/peer input -Respond appropriately throughout group process -Incorporate feedback -Complete activities toward goal attainment -Attain greater benefit from the group intervention than from 1:1 intervention

-The leader: -Provides active leadership -Instructs members as a group -Monitors and documents individual's participation and response to intervention -Provide individualized guidance and feedback -Documents person's progress toward goals defined in the individual intervention plan in objective, measurable, functional terms

-Occurs when there is sharing of group leadership between two or more therapists -Advantages: 1) each leader can assume different leadership roles, tasks and styles 2) both leaders can provide and obtain mutual support 3) observations and objectivity can increase 4) co-leaders can share knowledge and skills 5) co-leaders can model effective behaviors -Disadvantages may arise and must be dealt with for effective co-leadership: 1) splitting by group member(s) of one leader against the other 2) excessive competition among co-leaders 3) unequal responsibilities resulting in an unbalanced work load among co-leaders

-Altruism is the giving of oneself to help others -Catharsis is the relieving of emotions by expressing one's feelings -Universality comes from recognizing shared feelings and that one's problems are not unique -Existential factors address accepting the fact that the responsibility for change comes from within oneself -Self-understanding (insight) involves discovering and accepting the unknown parts of oneself -Family reenactment leads to understanding what it was like growing up in one's family through the group experience -Guidance comes from accepting advice from other group members -Identification involves benefiting from imitation of the positive behaviors of other group members -Instillation of hope is experiencing optimism through observing the improvement of others in the group -Interpersonal learning occurs when receiving feedback from group members regarding one's behavior (input) -Interpersonal learning also occurs by learning successful ways of relating to group members (output) -The conscious understanding and facilitation of these curative factors enhances the therapeutic value of a group

-Mosey (1996) provided a standard classification to identify major types of activity groups -Evaluation group -Thematic group -Topical group -Task-oriented group -Developmental group: 1) parallel 2) project 3) egocentric-cooperative 4) cooperative 5) mature group -Instrumental group -Role of the OTA in group work: 1) the OTA is active in all aspects of group work

-Purpose/focus: to enable client and OT practitioner to assess client's skills, assets, and limitation regarding group interaction -Assumption: to accurately evaluate an individual's functional abilities, one must observe the person in a setting where the skills can be demonstrate -Type of client: all individuals who will be involved in groups or who lack group interaction skills -Role of therapist: 1) selects and orients clients to group's purpose 2) selects activities that require collaboration and interaction and provides needed supplies 3) does not participate or intervene in group (except to maintain safety, if needed), but observes and reports members' interaction and functional skill level to the OT supervisor 4) asks for clients' inputs 5) validates assessment and establishes treatment goals with each individual client -Suitable activities: a tasks that can be completed in one session and require interaction to complete

-Purpose/focus: to assist members in acquiring the knowledge, skills, and/or attitudes needed to perform a specific activity -Assumptions: 1) improvement of ability to engage in activities outside of group can result from teaching of these activities within group 2) learning is facilitated by practicing and experiencing needed behaviors, with reinforcement of appropriate behaviors given -Type of client: 1) determined by the specific goals of the group 2) members' needs, concerns, and goals must match the objectives of the group 3) members must have a minimal group interaction skill level equal to a parallel group skill level -Role of therapist: 1) selects, structures, and grades suitable activities to teach needed skills 2) interventions vary according to group's level, needs, and goals 3) may range on a continuum from a highly structured, supportive director to a resource advisor 4) reinforces skilled development 5)attention is not paid to intra- and interpersonal conflicts unless they interfere with or are directly related to the activity -Suitable activities: 1) simulated, clearly defined, structured activities which enable members to practice and learn needed skills, attitudes, and knowledge within the group 2) activities selected are directly related to the skills needed to perform the activity outside of the group (eg. a cooking group to learn how to cook)

-Purpose/focus: to discuss specific activities that members are engaged in outside of group to enable them to engage in the activities in a more effective, need-satisfying manner -Concurrent topical groups are concerned with activities already engaged in outside of group (eg. a parenting skills group for parents of children with developmental disabilities) -Anticipatory topical groups are concerned with activities that are expected to be done in the future (eg. a discharge planning group for persons completing short-term rehabilitation) -Assumptions: 1) improvement of ability to engage in specific activities outside of group results from discussion of these activities 2) discussion of problem areas and potential solutions, reinforcement of appropriate behaviors, and experiential learning facilitate skill acquisition -Type of client: 1) individuals who share similar current or anticipatory problems in functioning 2) members must be at an ego-centric cooperative group skill level 3) sufficient verbal and cognitive skills to engage in discussion and to problem-solve are present -Role of the therapist: 1) facilitates group discussion while maintaining focus on the circumscribed activity 2) helps members problem-solve, gives feedback and support, reinforces skill acquisition 3) shares leadership with members; acts as a role model -Suitable activities: 1) group activity is a verbal discussion on a circumscribed activity that members are engaged in (concurrent) or will be engaged in (anticipatory) outside of group (eg. parenting, home maintenance, discharge from hospital, work, and leisure) 2) discussion may include members' current or anticipated fears and problems, potential solutions, and coping mechanisms 3) role play and "homework" may be utilized

-Purpose/focus: 1) to increase clients' awareness of their needs, values, ideas, feelings, and behaviors as they engage in a group task 2) to improve intra- and interpsychic functioning by focusing on problems which emerge in the process of choosing, planning and implementing a group activity -Assumptions: 1) activities elicit feelings, thoughts, and behaviors 2) activities are the means by which members can explore and experience these thoughts, feelings, and actions 3) through activities members can increase their self-awareness and practice new behaviors -Type of client: 1) individuals whose primary dysfunction is in the cognitive and socioemotional areas due to psychological or physical trauma 2) clients with fair verbal skills who can interact with others -Role of therapist: 1) initially, very active, defines group goals and structure 2) assists with activity selection, offers guidelines and suggestions 3) facilitates discussion among members 4) gives feedback and support 5) assist members in exploring relationships between thoughts, feelings, and actions 6) encourages members to experiment with new behavior patterns 7) as group develops, the leader is less active, helps members give more feedback and input; however, the OT practitioner remains the leader and ensures that the task is a means to the end, not the end itself -Suitable activities: 1) activities that are chosen by members and will create an end product or demonstrable service for the group itself or for persons outside the group 2) activities are selected, planned, and carried out by members with the understanding that the task is a means to study, understand, and practice behaviors

-A continuum of groups consisting of parallel, project, egocentric-cooperative, cooperative, and mature groups -Purpose/focus is to teach and develop members' group interaction skills -Assumptions: 1) learning principles are the basis. They are utilized throughout the five developmental levels 2) members are made aware of and helped to engage in appropriate group behavior 3) feedback and reinforcement are utilized. Learning of needed behaviors occurs when adaptive behaviors are reinforced and when maladaptive behaviors are not 4) maladaptive behaviors result from deviations, lags, or insufficiencies in development. These developmental deficiencies can be treated by participating in groups that are similar to the ones in which the skills would have been developed 5) subskills fundamental to mature group function must be acquired in a sequential manner -Types of clients: individuals with decreased group interaction skills -Overall role of the therapist: 1) for all group levels, the therapist assesses the individual's level and places them in the appropriate group 2) orients all members to groups' goals, structure, and norms 3) lower level groups require more active, direct leadership 4) as a group matures and attains a higher level of group interaction, leadership is shared among members

-Purpose/focus: 1) to enable members to perform individual tasks in the presence of others 2) to minimally interact verbally and non-verbally with others even though task does not require interaction for successful completion 3) to develop a basic level of awareness, trust, and comfort with others in group -Group leadership role: 1) provide unconditional positive regard to develop trust 2) actively fill all leadership functions and meets all members' needs 3) reinforce all behaviors appropriate to group, no matter how small 4) provide structure 5) facilitate interaction -Suitable activities: 1) members perform activities independently of others but in the presence of others 2) interactions are not required to successfully complete activity 3) activities should be similar or utilize common tools or materials to facilitate interaction and sharing 4) activities should be relevant to a person's ability, age, gender, and interest so he/she is more able to interact with and about it

Purpose/focus: 1) to develop the ability to perform a shared, short-term activity with another member in a comfortable, cooperative manner 2) to develop interactions beyond those that the activity requires 3) to enable members to give and seek assistance -Group leadership role: 1) select and structure activities that can be shared by two or more members 2) fulfill all of the members' needs while encouraging members to give and seek assistance and interact beyond activity requirements 3) reinforces cooperation, mild competition, sharing, and interactions -Suitable activities: 1) task is short-term and requires the participation of two or more people 2) task is shareable and requires interaction to successfully complete 3) group interaction, not project completion, is emphasized

-Purpose/focus: 1) to enable members to select and implement a long-range activity which requires group interaction to complete 2) to enable members to identify and meet the needs of themselves and others (eg. safety, esteem) -Group leadership role: 1) less of an active, direct leader 2) facilitate and allow members to fufill functional leadership roles to function independently 3) provide guidelines and assistance as needed 4) reinforce members' meeting needs of self and others 5) serve as a role model -Suitable activities: 1) activity allows 5-10 people to work together 2) it is selected and implemented by members 3) it is longer-term, requiring more than two meetings to complete

-Purpose/focus: 1) to enable members to engage in a group activity which facilitates free expression of ideas and feelings 2) to develop sense of trust, love and belonging, and cohesion 3) to enable members to identify and meet socio-emotional needs -Group leadership role: 1) act as an advisor, not as a direct leader 2) leader and members are mutually responsible for giving feedback, identifying and meeting needs, and reinforcing behavior -Suitable activities: 1) activities facilitate and allow for free expression of ideas and feelings 2) activity is secondary to need fulfillment and may not produce an end product

-Purpose/focus: 1) to enable members to assume all functional socio-emotional and task roles within a group 2) to enable members to reinforce behaviors which result in need satisfaction and task completion -Group leadership role: 1) acts as peer, an equal, a group member 2) members assume all roles with OT practitioner filling in only if and when needed to maintain group 3) all members satisfy needs and reinforce behavior while maintaining a balance between need satisfaction and task completion -Suitable activities: 1) activity requires a number of people to work together 2) it requires an end product or has an inherent time limit for completion 3) during group, activity may be stopped for members to explore what is going on within the group

-Purpose/focus: 1) to help members function at their highest possible level for as long as possible 2) to meet mental health needs -Assumptions: 1) individuals are functioning at their highest possible level and cannot change or progress 2) a supportive, structured environment which provides appropriate activities can prevent regression, maintain function, and meet mental health needs -Type of client: 1) individuals who have demonstrated in treatment an inability to change or progress 2) individuals who can't independently meet their mental health needs and/or need assistance to maintain function due to cognitive, psychological, perceptual-motor, and/or social deficits -Role of therapist: 1) provide unconditional positive regard, support, and structure to create a comfortable, safe environment for patients 2) select and design activities that will meet member's health needs and maintain highest possible level of function 3) assist members with activity as needed 4) make no attempt to change client -Suitable activities: 1) members can successfully complete activities with structure and assistance of therapist as needed 2) non-threatening and non-demanding 3) interesting, enjoyable and attractive to members 4) meet mental health needs of patients by enabling him/her to experience pleasure, have fun, socialize with others, etc. 5) maintain function by providing sensory, cognitive, perceptual-motor, and social input

-Provides a legal, serial record of client's condition, evaluation and re-evaluation results, course of therapeutic intervention and response to intervention from referral to discharge -Serves as an information source for client care, can be used by a covering therapist in absence of primary therapist -Enhances communication among healthcare or educational team members -Provides data for use in intervention, program evaluation, research, education and reimbursement

-Use legible handwriting (illegible notes may result in denial of reimbursement) -Be correct in grammar and spelling (errors detract from a professional presentation) -Be concise but complete (if it is not written down it does not exist and never happened; non-important, extraneous details [ie color of clothing] should be left out) -Be objective, with clear distinctions between facts and behavioral data and opinions and interpretations -Be current and accurate (occupational therapy notes/record are legal documents) -Follow institution and/or program guidelines, as well as reimbursers'/third party payers' guidelines ( non-compliance can result in services and/or payment being denied) -Only use standard, well recognized abbreviations (ie. ROM) (avoid alphabet soup; write in functional terms using uniform terminology consistent with AOTA's Standards of Practice and state practice acts) -Use person first language at all times (eg. "a mother with schizophrenia", or "the student with developmental delays", not "the schizophrenic", "the retarded") -Client's name and ID number should be on every page -No whiting out or blocking out of information is accepted (errors must be crossed out with one line, initialed, and dated. Black or blue ink is used at all times) -Include the date, including month, day and year -Identify the type of documentation (ie. initial note, progress note, discharge plan) -Comply with confidentiality standards (ie. do not put other clients' names in a note) -Informed consent for treatment can only be given by a competent adult (minors or adults determined to be incompetent must have written consent provided by a parent, legal guardian, person with power of attorney, or proxy) -Sign with a full signature (first and last name with professional designations) directly following content with no space left between content and signature -Countersignature by an occupational therapist on documentation written by an OTA or a student if required by law or the facility -All documentation may be subject to subpoena; therefore, documentation standards must be adhered to

-OTAs are qualified to write notes in medical charts -AOTA does not require OTA notes to be cosigned by an OT, but state and federal governments may consider cosigning a tangible way to demonstrate compliance with laws and regulations governing OTAs -AOTA does recommend OTA notes for inclusion in medical charts and Individualized Education Plans (IEPs) be cosigned by an OT, since these are official documents and are subject to subpoena

-Identification and background information -Evaluation and reevaluation documentation -Intervention plan documentation -Intervention implementation documentation -Discharge plan documentation

-Name, age, sex, date of admission, treatment diagnosis, and case number if one exists -Referral source, reason for referral, chief complaint relevant to OT's domain of concern -Pertinent history that indicates prior levels of function and support systems, including applicable developmental, educational, vocational, socioeconomic, and medical history. This can be brief -Secondary problems or preexisting conditions that may affect function or treatment outcomes -Precautions, risk factors and contraindications, medications, surgery dates

-Assessments administered and the results -Summary and analysis of assessment findings in measurable, functional terms (sufficient baseline objective data; in reevaluation, compare findings to initial findings; indicate change, if any) -References to other pertinent reports and information including relevant psychological, social, and environmental data -Occupational therapy problem list, specific and sufficient to develop intervention plan -Recommendations for occupational therapy services (can include recommendation that no OT services are indicated) -Client's understanding of current status and problems, his or her subjective complaints -Client's interest and desire to participate in therapy

-A prioritized problem list -Goals related to problem list and indicating potential for function and improvement -The structure of a goal statement: 1) the person who will exhibit the skill, almost always written as "the patient/client will". However, the caregiver, family member, and/or teacher may be the focus of the goal 2) the desired functional behavior that is to be demonstrated or increased as the outcome of intervention 3) the underlying factors (eg. performance component deficits) that must be remediated to achieve functional outcome 4) the circumstances under which the behavior must be performed or the conditions necessary for the behavior (eg. independent, with cueing, with assistance) 5) the degree at which the behavior is exhibited (eg. 3 out of 4 times, minimum number of repetitions) -Short and long term goals written in a SMART manner: 1) Specific - for example, not "increase self-care skills"; rather "develop ability to button shirt using non-dominant hand" 2) Measurable - as to number of times or a percent 3) Attainable - as to what can be realistically achieved. For example, one hundred percent return is unlikely 4) Relevant - to roles and expected environment 5) Time-limited - anticipated time to achieve goals (time allotted for goal attainment must be relevant to setting's LOS (eg. in acute care, goals are measured in days whereas long term care, weekly or monthly goals are acceptable) -Long term goals must indicate the final desired functional outcome before discharge, regardless of LOS: 1) a clear reason for skilled therapeutic intervention 2) statement of potential functional outcome that is clearly related to goal -Activities and/or treatment procedures and methods related to stated goals and problems -Type, amount, frequency of treatment needed to accomplish goals (how many times/week/day? how long are sessions?) -Explanation of treatment plan to client and a provision of statement of goals in client's words

-Activities, procedures, and modalities used -Client's response to treatment and the progress toward goal attainment as related to problem list -Goal modification when indicated by the response to treatment. Rationale for changes in goals needed -Change in anticipated time to achieve goals with rationale for change and new time frame specified -Attendance and participation with treatment plan (attendance can be a check format) -Statement of reason for individual missing treatment -Assistive/adaptive equipment, orthoses, and prostheses if issued or fabricated, and specific instructions for the application and/or use of the item, including wearing schedule and care -Patient-related conferences and communication with physicians, third party payers, case manager, team members, etc -Home programs developed and taught to client and/or caregiver(s) -Client's and/or caregiver's compliance with home program

-Summary of evaluation and intervention -Compare initial and discharge status -Specify number of sessions, goals achieved, and functional outcome -Reason for discharge: 1) goal attained 2) client no longer making functional gains 3) client refuses or is noncompliant with intervention 4) client moves to another location 5) setting not appropriate to individual's needs -Home programs to be followed after discharge -Client and family education -Equipment provided and/or ordered -Follow-up plans/recommendations with rationales -Referral(s) to other health care providers and community agencies

-Problem Oriented Medical Record (POMR): a system of providing structure for progress note writing that is based on a list of problems based on assessment (SOAP notes) -Consultation reports: meetings and/or phone conversations with team members, other professionals, the individual, and his/her caregivers -Critical incident reports: significant, out of the norm events that may occur during OT evaluation or intervention (eg. the individual slips during a transfer) -All of the above must comply with general documentation standards and contain all fundamental components of documentation

-Subjective: information reported by the client, family, or significant other -Objective: diagnosis, medical information and history, and measurable, observable data obtained through formal assessments -Assessment: therapist's interpretation and clinical reasoning based on objective data includes analysis of client's status and goals and a prioritized problem list -Plan: the therapist's specific plan of intervention to resolve identified problems and meet stated goals

-To be reimbursed, OT services must be properly coded and billed, as required by reimbursers -Practitioners must represent their services in terms of diagnosis and procedure codes -Diagnosis codes describe person's condition or medical reason for requiring services: 1) the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most frequently used diagnosis-coding system in the US 2) ICD-9-CM is updated annually so all billing documentation must use current version. 3) each service, procedure, supply, or piece of equipment must be related to the ICD-9-CM code -Procedure codes describe the specific services provided by the health care professional: 1) HFCA Common Procedure Coding System (HCPCS) is most widely used 2) HCPCS includes the Physician's Current Procedural Terminology (CPT) 3) the most current HCPCS and CPT codes must be used as they are updated annually 4) specific codes that most closely describe service(s) provided should be used. Each procedure, modality, and/or treatment should be coded -Specific billing forms are used by institutional providers (ie. hospitals and home health agencies) and by physicians and OTs in independent practice for Medicare, Medicaid, and most states' workers' compensation programs -OTAs are generally not eligible for direct payment because they require supervision and do not perform evaluations

-The use of certain words, terms, and/or physician's errors can result in delay, denial, and/or discharge from services -Avoid these in all documentation, unless they are true and accurate representations of a client's status -If a client has met his/her goals and/or is no longer making significant functional gains, this must be documented and the client must be discharged from services -Words to avoid, for they do not reflect progress: 1) chronic 2) status quo, no change in status 3) maintaining 4) little change 5) plateau 6) making slow progress 7) stable or stabilizing -Words to avoid, for they do not reflect potential for improvement: 1) same as 2) uncooperative, noncompliant 3) dislikes therapy 4) confused/disoriented 5) inability to follow directions 6) patient refused to participate 7) custodial care needed 8) treatment repeated 9) repeated instruction 10) unmotivated 11) extreme depression 12) fair to poor potential 13) chronic/long term condition 14) general weakness -Errors in physician's orders, for they can result in denial or delay of payment for OT services: 1) incomplete or non-specific orders 2) orders with a span of frequency over the duration of intervention (eg. 2 to 3 x wk for 4-6 wks) 3) orders that do not state a specific type of intervention (eg. activities, splint or equipment, as needed) 4) orders that cover only evaluation but intervention has been initiated 5) order is specific to a certain type of treatment, but the treatment plan does not include it 6) order does not include duration of treatment 7) the plan changes mid-month but the order is not updated to meet the new plan change 8) there is no discharge order or there is no order immediately after treatment ends

-Many private reimbursers and state Medicaid programs follow federal Medicare guidelines, so if documentation meets Medicare standards it will generally be acceptable to other insurers -It is advisable to get copies of state and individual insurers' guidelines for OT services, as adherence to these guidelines will be critical for reimbursement. -Previously state standards and guidelines for documentation apply to reimbursement for Medicare

-Required from a physician as defined by state practice acts -The certification could be: 1) a signature on the bottom of the note 2) an MD signed 700 or 701 form 3) a sheet stapled to the note with the MD signature and a statement reading "I certify that I approve of the attached treatment plan." -Make sure diagnoses are acute, not chronic: 1) rephrase the diagnosis for the physician if needed 2) use onset dates of within 60 days of admission to services, if possible (example: instead of rheumatoid arthritis (RA) x 10 years, use acute exacerbation of RA as of 5-10-01)

-Content must indicate that the treatment shows a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgement, knowledge, and skills of a qualified therapist. This statement is as per Medicare -Skilled rehabilitation intervention is mandatory. (delineate the specific skilled care rendered. This is the biggest cause for retroactive denial; notes must show therapeutic intervention. Example dressing alone does not indicate therapeutic concerns. Decreasing extensor tone to accomplish dressing meets these criteria) -Skilled care rendered must match the diagnosis and the physician's order -Services must be unique to OT and not sound like PT or SLP. Medicare does not pay for duplication of services -In home care, homebound status due to functional limitations must be clearly delineated (if the diagnosis may not render the individual homebound, explain why this particular person is homebound; do not give a reviewer any doubt that this person does not meet Medicare homebound criteria [eg. do not state client not at home when you arrive. Rather state there was no answer to a locked door]) -Document honestly, but not over optimistically. Medicare reviewers are interested in determining the need for continued intervention (write the note in such a way that the patient remains sick and needs further care instead of the patient improving rapidly; provide behavioral observations that substantiate need for further care) -Practical improvement is noted with functional change (if improvements are not made, the client should be discharged in a timely fashion; if there is a reason for the lack of progress, it should be noted) -Documentation must also demonstrate that the patient is making significant functional improvement in a reasonable and generally predictable period of time: 1) some improvement must be made at least on a weekly basis; otherwise treatment will be considered maintenance 2) if progress is slower than expected, document extenuating circumstances and/or limiting factors (eg. secondary diagnosis) 3) Medicare does not reimburse for maintenance treatment 4) payment for designing a maintenance program and making periodic but infrequent evaluations of the program's effectiveness is provided -The service must be reasonable and necessary (was the service effective and completed in a timely fashion? in long term care, if the treatment does not lessen the amount of care needed by staff, what made the service worthwhile?)