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TUS,GroupProcess,Documentation,TreatmentPlanning [OT7] Ms.A

TREATMENT TOOLS THERAPEUTIC USE OF SELF The use of oneself in such a way that one becomes an effective tool in the evaluation and intervention process. It involves a planned interaction with another person in order to alleviate fear or anxiety, provide reassurance, obtain necessary information, provide information, give advice, and assist the other individual to gain more, appreciate of, more expression of , and more functional use of his or her latent inner resources. (Mosey 1986) ELEMENTS: 1. Understanding = accept the patient as he/she is 2. Neutrality = therapist is tolerant and interested in the patients painful emotions 3. Caring = therapist is able to communicate to the patient what the patient expects from the therapist.

THE THERAPEUTIC RELATIONSHIP IN OT A primary necessary ingredient in the therapeutic process. In OT, the relationship with the patient is not the sole focus of treatment but rather it is believed that the clinicians therapeutic use of self is a necessary requirement to a relationship. Similar to the use of purposeful activity in occupational therapy.

HUMANISTIC ROOTS OD THE PROFESSION The theoretical base for treatment lay in the principles of moral treatment and the psychobiological theory of Adolph Meyer.

PURPOSE OF THERAPEUTIC USE OF SELF Provide reassurance and or information Give advice Alleviate anxiety and fear Obtain needed information - improve and maintain function - promote growth & development - increase coping skills

ESSENTIAL CHARACTERISTICS OF THERAPEUTIC USE OF SELF 1. Perception of individuality and uniqueness of each person. 2. Respect for the dignity and rights of each individual regardless of past or present situation or possible future potential. 3. Empathy to enter and share the experiences of an individual while maintaining one s own sense of self. 4. Compassion to be kind and want to alleviate pain and suffering. 5. Humility to recognize ones own limitations. 6. 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. 7. Honesty to be truthful and straightforward. 8. Relaxed manner to leave other concerns aside and schedule sufficient time to be with the person so that external issues do not impede on the relationship. 9. Flexibility to modify behaviors and to meet the needs of each individual and deal with the circumstances as they arise or change. 10. Self awareness to accurately know ones assets and limitations and not to be able to make changes as needed to interact more effectively in therapeutic relationships. 11. Humor to appropriately recognize and or use what is amusing and comical. COMMON ISSUES AND RESPONSES 1. Negative Attitudes, Fear or Hostility towards individuals who are different and or towards the unknown. 2. Resistance to establishing rapport due to past rejections and the fear of future rejection. 3. Communication Difficulties = incongruence between verbal & non-verbal communications resulting in confusion.

4. Language Difficulties = psychiatric symptoms 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 or lack of comprehension between individuals = misinterpretations can occur due to differences in primary language. 5. Dependency that is excessive and hinders the individuals growth towards interdependence and or independence. 6. Difficulty in expressing feelings due to personal reticence or cultural backgrounds. 7. Over involvement that results in a loss of objectivity or a fear of involvement that leads to detachment. 8. Difficulty with developing an individual therapeutic style that is a comfortable fit so that being a therapist becomes a natural part of ones self. THE GROUP PROCESS GROUP DYNAMICS = 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 DEVELOPMENT 1. Origin - involves the leader comprising the group protocol and planning for the group (size, member characteristics, location of meetings). 2. Orientation - involves members learning what the group is about, making a preliminary commitment to the group, and developing initial connections with other members. 3. Intermediate - involves members developing interpersonal bond, group norms, and special member roles through involvement in goal-directed activities and clarifications of groups purposes. 4. Conflict -involves the members challenging the group structure, purposes and or processes, and is characterized by dissension and disagreements among members. Unsuccessful resolution of this phase results in dissolution of group. Successful resolution of this phase results in modifications to the group that are acceptable to the members, enabling the group to proceed to the next phase of the development. 5. Cohesion - members regrouping after the conflict with a clearer sense of purpose and a reaffirmation of group norms and values, leading to group stability. 6. Maturation - members using their energies and skills to be productive and to achieve the groups goals. 7. Termination - involves dissolution of the group due to lack of engagement of members, inability to resolve conflict, administrative constraints, goal attainment or task accomplished. GROUP NORMS The standards of behavior and attitudes that are considered appropriate and acceptable to the group. Behavior that falls outside of the groups range of acceptable behavior is considered deviant and is often negatively sanctioned. Norms can be explicit and clearly verbalized. Norms can also be non-explicit and non-verbalized. Norms can vary in different groups and can change as group develops and or membership changes

THERAPEUTIC NORMS Encourage self-reflection, self-disclosure and interaction among members Reinforce the value and importance of the group by being on time and well-prepared Establish an atmosphere of support and safety Maintain confidentiality and respect Regard group members as effective agents of change by not placing the group leader in the expert role

GROUP LEADERSHIP STYLES AND MEMBERSHIP ROLES 1. Directive - the therapist is responsible for the planning and structuring of much of what it takes places in the group. GOAL: Task accomplishment -needed when the members cognitive, social, and verbal skills as well as engagement are limited. 2. Facilitative - the therapist shares responsibility for the group and or group process with members. - advised when members skill levels and engagement are moderate GOAL: Members acquire skills through experience. 3. Advisory - therapist functions as a resource to the members, who set the agenda and structure the groups functioning. - assumed when members skill and engagement are high. GOAL: have members understand and self-direct the process DOCUMENTATION AND TREATMENT PLANNING Documentation - provides a legal, serial record of clients condition, evaluation and re-evaluation results, course of therapeutic intervention and response to intervention from referral to discharge. Serves as an information resource for client care, can be used by a covering therapist in absence of the primary therapist.

Purpose of Documentation: Enhances communication among healthcare or educational team members. Provides data for use in intervention, program evaluation, research education & reimbursement.

General Documentation Standards Use eligible handwriting Be correct in grammar and spelling Be concise but complete Be objective, with clear distinction between facts and behavioral data, opinions and interpretations Be current and accurate Follow instructions and or program guidelines Only use standard, well-organized abbreviations Use first person language at all times Clients name and ID number should be on every page No whiting out or blocking out of information is accepted Dates must be complete Identify the type of documentation Comply with confidentiality standards Informed consent for treatment can only be given by a competent adult Sign with a full signature

CONTENT OF DOCUMENTATION 1. Identification and Background Information Name, age, sex, date, treatment diagnosis, and case number Referral source, reason for referral, chief complaint relevant to OTs domain of concern Pertinent history that indicates prior levels of function and support system Secondary problems or pre-existing conditions that may affect the function of treatment outcomes Precaution, risk factors, and contraindications, medications, surgery dates

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Evaluation and Re-evaluation Assessments administered and results Summary and analysis of assessment findings in measurable, functional terms References to other pertinent reports and information including relevant psychological, social and environmental data OT problem list, specific and sufficient to develop an intervention plan. Recommendations for OT services Clients understanding of current status and problems , his/her subjective complaints. Clients interest and desire to participate in therapy.

INTERVENTION IMPLEMENTATION DOCUMENTATION (NOTES) Activities, procedures, and modalities used Clients response to a treatment and progress toward goal attai nment as related to the 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 Statement of reason for individual missing treatment Assistive and adaptive equipment, orthoses, and prostheses if used 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. 3rd party payers, case manager, team members, etc. Home programs developed competence of work program Specified documentation formats: Problem Oriented Medical Record (POMR) POMR -a system of providing structure for progress note writing that is based on a list of problems based on assessment. SOAP Notes S (Subjective) O (objective) A (Assessment) P (Plan)

DISCHARGE PLAN DOCUMENTATION 1. 2. 3. 4. 5. 6. 7. 8. 9. Summary of Evaluation and Intervention Compare initial and discharge status Specify number of sessions, goals achieved, and functional outcome Reason for discharge Goals attained Client no longer making functional gains Client refuses or is non-compliant with intervention Client moves to another location Setting not appropriate for individual s needs Home programs to be followed after discharge Client and family education Equipment provided and or ordered Follow-up plans or recommendations with rationales Referrals to other health care providers and community agencies

INTERVENTION PLAN DOCUMENTATION 1. 2. 3. 4. 5. A prioritized problem list Goals related to problem list Activity or treatment procedures Length of time for treatment Explanation

A PRIORITIZED PROBLEM LIST Values, interest and needs of the individual, family, significant others, and caregiver Individuals current and expected roles, and environmental context The treatment settings characteristics, resources and limitations (LOS) The likelihood that the problem will respond to intervention within the given setting

GOALS RELATED TO PROBLEM LIST 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. STGs or OBJECTIVES: the component sub skills which are to be achieved over shorter time frames, leading to the attainment of long term goals. Short and Long Term Goals must be written in a SMART Manner (Specific, Measurable, Attainable, Relevant, and Time-limited)

STRUCTURE OF GOAL STATEMENT: STGs (ABFCD) A (Audience) - the person who will exhibit the skill, almost always written as the patient/client will. However, the caregiver, family/teachers may be focus of goal. B (Behavior) - the desired functional behavior that is to be demonstrated or increases as the outcome of intervention. C (Circumstance) - the circumstances under which the behavior must be performed or the conditions necessary for the behavior (independent, with cueing, etc.) F (Factors) D (Duration) Example A- The patient will B- B- follow a 3 step verbal direction F - Sort, fold, put away laundry C- 1 verbal clue D- 3/3 trials LTG: to develop communication skills necessary for social participation STG1 with multisensory cueing, patient imitate 5 signs/gestures in trials.. ACTIVITY OR TREATMENT PROCEDURES TUA: imitating gestures with therapist LENGTH OF TIME FOR TREATMENT 1 hr. session, 3 x a week for the next 6 months EXPLANATION Explanation of treatment plan to client and a provision of statement of goals in clients words. - the underlying factors that must be remediated to achieve functional outcome - the degree in which the behavior is exhibited (e.g. times, minimum # of repetitions)