Foundational Knowledge

• Initial assessment (initial evaluation)

  Reflects the current status of the client at the start of recreational therapy services; evidence-based treatment plan is created
• Session Notes


  Documenting the date the service was rendered, interventions utilized, and client's performance related to treatment objectives
• Progress Notes


  Summary of the client's performance over a specific period of time; this is where the evidence-based treatment plan may be revised
• Discharge/Transition Note


  Written when recreational therapy services are terminated; reasons include client achieving treatment objectives, declined participation, coverage was terminated, client is discharged. Includes summation of client's performance related to treatment objectives from start date to end date of services
• Which Code of Ethics is related to patient documentation?

  Principle 10: Compliance with Laws and Regulatons
• Functional Assessment Scale (FAS)


  Assesses the level of assistance a client requires at the current level of functioning
• What are the assessment preparation steps?

  Obtain a medical order (if needed), review transfer note and medical chart, research, obtain information from secondary source (as needed), prepare for assessment
• Medical order 


  A written order from the treating physician in the client's medical chart; not every client needs a medical order for recreational therapy services
• Transfer Note


  A packet of medical documents from the client's prior place or admission; tells the client's status before transferring to another hospital
• Medical Chart


  Typically a binder with tabs or solely electronic; contains current medical documents and includes all information while the client was at a previous hospital
• Research


  An essential step because it allows the CTRS to research things they don't know enough; evidence-based practice
• Secondary Sources


  Healthcare team members, family/caregivers
• How do you prepare before meeting a client for an assessment?

  Determine which skills you will MOST LIKELY want to assess based on diagnosis, questions you want to ask to client or secondary sources, and choose modalities that will allow you to assess identified skills
• Parameters and Precautions


  Guide the therapist's clinical decisions about appropriate activities and meeting client needs; ensure the therapist is monitoring throughout sessions
• International Classification of Functioning, Disability, and Health (ICF)

  Codes for reporting and analyzing health interventions; codes are developed, maintained, and copyrighted by WHO
• Assessment of Life Habits (LIFE-H) & Measure of the Quality of the Environment

  A self-report based on the person's perception of difficulty, assistance required, and degree of satisfaction to complete 12 domains of functioning; used for older adults with disabilities
• Community Integration Questionnaire (CIQ)

  Assess social role limitations and community interaction; used for adults with TBIs, acquired brain injuries, SCIs, and stroke
• Depression, Anxiety, and Stress Scale (DASS) 


  Assesses the fundamental symptoms of depression, anxiety, and tension/stress; used on War Veterans/War Widowers, acquired brain injury, phobias/anxiety disorders, students, etc.
• Developmental Assessment of Young Children (DAYC-2)

  To help identify children (birth through 5 years) who are significantly below their peers in cognition, communication, social-emotional development, physical development, and adaptive behavior abilities; monitor a child's progress in special intervention programs
• Dynamic Gait Index (DGI)


  Developed to assess the likelihood of falling in older adults; designed to test eight facets of gait
• Family APGAR


  A standardized assessment tool that measures perception of their social support system; used with any population but individuals must be able to communicate thoughts/feelings and should have no minimal cognitive impairment (12+ years)
• Free Time Boredom (FTB)


  Identify the degree to which the participant is bored in the four components that make up boredom (meaningfulness mental involvement, speed of time, physical involvement); must be able to read at 4th grade level and has a mental age of 11 and above
• Leisure Attitude Measure (LAM)

  To review and quantify the participants' attitude toward leisure on three different levels--cognitive, affective, and behavioral; must have moderate to no cognitive impairment and Ranch 7 or above
• Leisure Interest Measure (LIM)


  Measure how much interest the client has in each of the eight domains: physical, outdoors, mechanical, art, service, social, cultural, reading; must have moderate to no cognitive impairment and Ranch 7 or higher
• Leisure Motivation Scale (LMS)


  To measure a client's motivation for engaging in leisure activities; uses a questionnaire and scaling system that measures whether clients most frequently/less likely to engage in leisure for intellectual, social, competency-mastery, or stimulus-avoidance purposes
• Leisure Satisfaction Measure (LSM)


  Measure the degree to which a client perceives his/her general "needs" are being met through leisure; uses a questionnaire and scale to determine whether leisure activities provide psychological, educational, social, relaxation, physiological, or aesthetic benefits
• Mini-Mental State Exam (MMSE)


  To screen for cognitive impairment (e.g. orientation, registration, attention and calculation, delayed recall, and language); scores range from no impairment (24+) to severe impairment (0-17)
• Modified Checklist for Autism in Toddlers, Revised with Follow-Up (MCAT-R/F)


  Consists of 20 questions that the child's parent/caregiver completes to assess risk for ASD; scores range from low risk (0-2) to high risk (8-20)

  Second stage: Follow-up which is getting additional information about at-risk responses; positive = 2+, negative = 0-1
• Modified Differential Emotions Scale (mDES)

  Extent to which positive and negative emotions have been experienced within a particular time frame
• Montreal Cognitive Assessment (MoCA)

  Rapid screen of cognitive abilities designed to detect mild cognitive dysfunction (attention, concentration, executive functions, memory, language, etc.); 26+ is considered normal
• Pain Scale


  To indicate the extent of pain a person is experiencing; ranges from 0 (no pain) to 10 (severe pain)
• Pressure Ulcers


  Stage 1: Skin isn't broken but is red or discolored. Redness or change in color doesn't fade within 30 minutes after pressure is removed

  
  

  Stage 2: Topmost layer of skin is broken which creates a shallow open sore; drainage may or may not be present

  
  

  Stage 3: The break in skin extends through dermis (second layer of skin) into the subcutaneous and fat tissue; wound is deeper than in Stage 2

  
  

  Stage 4: Breakdown extends into muscle and can extend as far down as the bone; lots of dead tissue and drainage are preset
• Reintegration to Normal Living Index (RNLI)


  Assesses quantitatively the degree to which an individual feels they have been able to return to a normal life (client's perception); there are 11 statements and client answer based on whether it relates to them
• WHO-DAS 2.0


  Generic disability assessment of health and disability; a self-report instrument related to the extent of difficulty performing specific tasks (e.g. cognition, mobility, self care, getting along, life activities, participation); questions are based on client's perception of difficulty
• WHO-QOL-BREF


  Measure a person's perception of their life quality in four domains (physical, psychological health, social relationships, environment)