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Assessment Protocol

Lexi Mireles

RECTH 3360

April 8th, 2020

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Assessment Protocol
Utah State Hospital
Preparation
 Protocol Review
 Recreational Therapist needs to go over assessment protocol and update as
needed.
 Record Review
 Review family history of patient.
 Review the patient’s history.
 Information on Diagnosis
 Interview
 Interview should be done within 72 hours upon entering the facility.
 Gather interview questions.
Environment
 The environment for the interview should be in an inviting and
comfortable space. The interview should last at least 30 minutes
depending on time and demand of the Recreational Therapist that day.
 The environment should be in an open space with little to no distraction.
 The space should be well lit, and the RT should be aware of the
temperature.
Supplies
 To prepare for the interview and assessment the RT should gather the
following:
o Notebook or other method of writing for RT
o Pens for patient and RT
o A hard surface to write on (e.g. desk, clipboard, etc.)
o Copy of Interview Questions (See Below)
o Copy of Comprehensive Evaluation in Recreational Therapy
–– Psych/Behavioral, Revised (CERT –– Psych/R)
 Observation
 Go over the CERT Psych/R prior of working with the patient to
understand behaviors to observe.
Assessment Administration
 Protocol Review: N/A
 Record Review: N/A
Interview
 The initial interview is essential to create a trusting relationship between
the client and the therapist.
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 The interview will take 30-60 minutes and administered open-ended

questions.
 Interview questions will be standardized; however, variations of
questions are allowed to help with the natural flow of the conversation.
Introduction Between Recreational Therapist and Patient.
 Recreational Therapist will introduce themselves and the facility.
 Introduction should include an introduction of what Recreational Therapy
is and its role in within the facility.
 Introductions should be welcoming and inviting, allowing the patient to
feel more comfortable. It should be clarified that questions should be
answered to the best of their abilities.
Face-to-face Interview
 Interview will be administered face-to-face in an environment with little
to no distraction.
 Therapist will ask questions from the interview questions (attached).
 The interview should try to get to as many questions as they can without
rushing the patient.
Observation
CERT-Psych
 Section 1 (General) and Section 2 (Individual) should be completed after
the patient’s initial interview.
 Section 3 (Group Performance) should be completed after the first group
activity upon arriving to the facility.
Scoring
 Protocol Review: N/A
 Record Review: N/A
 Interview: Notes gathered during interview should be taken for easy access for
further observation.
 Observation
o Calculate each section of CERT- Psych using the following:
 General Scores range from 0-20 with scores between 0-5 showing
outstanding, good and functional performance. A score of 6-20
shows problematic performance.
 Individual Scores range from 0-40 with scores between 0-10
showing outstanding, good and functional performance. A score of
11-40 shows problematic performance.
 Group Scores range from 0-40 with scores between 0-10 showing
outstanding, good and functional performance. A score of 11-40
shows problematic performance.
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Analysis and Interpretation

 Record review
o Note the following
 Age
 Diagnosis
 Gender
 Any information relating to the diagnostic protocol
 Interview
o Social Functioning
 Patient’s support system:
 Friends
 Family
 Patient’s understanding of relationship between friends and family
 Patient’s confidence with setting boundaries with friends and family
o Cognitive Functioning
 Patient’s ability to problem solve and make decisions.
 Patient’s memory ability
 Patient’s interest in learning
o Emotional Functioning and Coping Skills
 Patient’s coping skills
 Patient’s understanding of what causes certain emotions.
 Patient’s interest in participating in activities that help regulate
emotions.
o Physical Functioning
 Self-Care: Eating, sleeping, etc.
 Patient’s physical strength and weaknesses.
 Patient’s history of physical changes.
o Spiritual Functioning
 Patient’s understanding of spirituality.
 History of spiritual practices (e.g. meditation, religious practices, etc.)
o Leisure
 Patient’s understanding of leisure.
 Patient’s leisure interest.
 Activities the patient does not enjoy.
o Patient’s Expectation
 Goals and expectation from treatment.
 Observation
o General
A. Attendance
1. Attends
2. Attended, but late or left early
3. Absent occasionally without cause
4. Rarely attends
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5. Refuses or never attends

B. Appearance (for ratings of 2 or 3 underline the behavior being rated)
1. Appropriate
2. Disarranged clothing
3. Suggestive dress or any wrinkled and soiled clothing
4. Very meticulous or very wrinkled and soiled clothing
5. Very wrinkled and soiled clothing and poor hygiene
C. Attitude Toward Recreational Therapy
1. Enthusiastic
2. Interested
3. Indifferent
4. Intense dislike
5. Hostile
D. Coordination
1. Well-coordinated gait
2. Shuffling gait
3. Stiff, awkward gait
4. Spastic, draws attention
5. Unable to walk
E. Posture
1. Erect
2. Round shouldered
3. Slouched
4. Sagging
5. Limp, unable to participate
o Individual Performance
A. Response to Therapist’s Structure: One-to-One
1. Accepts well
2. Accepts with question
3. Occasionally accepts
4. Rarely accepts
5. Rejects
B. Decision Making Ability
1. Independent
2. Needs support
3. Indifferent
4. Indecisive
5. Totally dependent
C. Judgment Ability
1. Good ability
2. Needs occasional advice
3. Needs constant advice
4. Irresponsible
5. No ability
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D. Ability to Form Individual Relationships (Evaluate after three days)

1. Relates readily
2. Hesitant
3. Superficial
4. Distant
5. Rejecting
E. Expression of Hostility (a or b)
A.
1. Appropriate
2. Verbally aggressive (curses, slanders, etc.)
3. Belligerent (sulks, refuses)
4. Physically destructive
5. Physically combative
B.
1. Appropriate
2. Withdraws
3. Verbally negates self
4. Verbally abuses self
5. Suicidal
F. Performance in Organized Activities
1. Grasps situation
2. Needs minimal instructions
3. Needs frequent instructions
4. Needs constant instruction to participate
5. Unable to participate
G. Performance in Free Activities (Evaluate from evening and weekend
activities)
1. Acts on own initiative
2. Participates after activity starts
3. Participates after encouragement
4. Starts and stops: frequent encouragement required
5. No interest and/or refuses
H. Attention Span
1. Attends to activity
2. Occasionally does not attend (preoccupied)
3. Frequently does not attend (distracted)
4. Rarely attends to activity
5. Does not attend (detached)
I. Frustration Tolerance Level
1. Participates without appearing frustrated
2. Occasionally becomes frustrated
3. Often becomes frustrated
4. Appears frustrated most of the time
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5. So frustrated unable to participate

J. Strength/Endurance
1. Good tone
2. Able to participate in ¾ of any activity
3. Tires if activity requires being on feet
4. Tires even in seated activities
5. Unable to participate
o Group Performance
A. Memory for Group Activities
1. Good recall
2. Remembers most activities
3. Remembers few activities
4. Confused, seldom remembers activities
5. No recall
B. Response to Group Structures
1. Accepts well
2. Accepts with questions
3. Rarely accepts
4. Rejects structure
5. Rejects structure and become hostile
C. Leadership Ability in Group
1. Can be a leader
2. A leader if encouraged
3. Co-leader ability
4. Some leadership with constant support
5. No ability
6.
D. Group Conversation (a or b)
A.
1. Converses well with groups
2. Converses well but sometimes is too loud
3. Overly talkative at times
4. Overly talkative during most of the activity
5. Incessant talking
B.
1. Converses well with group
2. Converses only occasionally
3. Converses but is guarded
4. Attempts to converse but appears to block
5. Unable to converse with groups
E. Sexual Role in Group (Indicate if the problem is in actions or perception)
1. Meets society’s norms
2. Inappropriate dress, speech or body language
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3. Por understanding of personal space

4. Inappropriate physical contact or fear of appropriate contact
5. Unable to control sexual impulses or fear
F. Style of Group Interaction (a or b)
A.
1. Assertive
2. Tries to control
3. Argumentative
4. Dominant interrupter
5. Hostile
B.
1. Assertive
2. Assertive with support
3. Only sits quietly
4. Detaches from group, participation
5. Withdraws from group and participation
G. Handles Conflict in Group When Indirectly Involved
1. Handles well
2. Sometimes will not get involved
3. Personalizes the conflict
4. Rarely gets involved
5. Ignores or runs away
H. Handles Conflict in Group When Directly Involved (a or b)
A.
1. Handles well
2. Verbally defensive
3. Verbally aggressive
4. Becomes physically agitated
5. Becomes physically abusive
B.
1. Handles well
2. Apologetic
3. Self-depreciating
4. Withdraws, but continues in activity
5. Withdraws from activity
I. Competition in Group (a or b)
A.
1. Sufficient
2. Occasionally is aggressive
3. Often overcompetitive
4. Must always win
5. Lies or breaks rules to win
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B.
1. Sufficient
2. Tries, but occasionally gives up
3. Tries, but often gives up
4. Doesn’t try to win
5. Doesn’t care/refuses to participate
J. Attitude Toward Group Decision
1. Follows group decisions
2. Accepts most of the time
3. Hesitant
4. Resists
5. rejects
Reporting
o Assessment documentations are filed into the facility’s medical records.
 Any additional notes from the Recreational Therapist will also be filed
into the facility’s medical record.
Reassessment
o Reassessment needs to be completed every month and prior to discharge.
o Reassessment will evaluate the patient and the program to get an understanding of
the individual’s progress within the program.
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References
Burlingame, J., & Blaschko, T.M. (2010). Assessment tools for recreational therapy and
related fields (4th ed.). Ravensdale, WA: Idyll Arbor, Inc.
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Interview Questions
Therapist Introduction
 Hello, my name is Lexi and I am a Recreational Therapy student.
 A recreational therapist is someone who wants to help people by giving them the
tools and knowledge to be able to live their best lives.
 My purpose today is to ask you some questions and to get to know you better.
Client Introduction:
 Tell me about yourself?
 Tell me about how school is going for you?
 Can you tell about why you think are we here today?
Activity to Guide Interview:
Not appropriate
Interview Questions 
Social: 
 Why are your friends important to you?
 What kinds of activities do you enjoy participating with your friends?
 How would you describe your relationship with your friends?
 How would you describe your relationship with your family?
 How do your friends contribute to your happiness?
 How do your family contribute to your happiness?
 How have your friends impacted your life in a negative way?
 How have your family impacted your life in a negative way?
Physical:
 What does it mean to you to be physically healthy?
 Why do you think it is important to be physically healthy?
 What types of physical activities do you participate in?
 Do you experience any sort of physical pain or discomfort? 
 Can you describe that pain for me?
 What kinds of physical changes have you noticed about yourself over the last
several months?
o If you have noticed changes, what do you think is reason for these changes?
 Can you describe your sleeping habits?
 How would you describe your eating habits?
 What are somethings you do to take care of yourself?
 Why do you think taking care of yourself is important?
Emotional:
 What are ways you handle difficult situations?
 How are you feeling right now?
 What were your emotions before meeting today?
 What things made you feel this way?
 What are some ways you make yourself happy?
 What are the things in your life that make you upset?
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Cognitive: 
I’m going to ask you a series of question and I want you to answer by saying “never,”
“sometimes,” or “always” and why you answered the way you did.  
Series of question using 1-3
1- Never
2- Sometimes
3-Always
-  Do you have a difficult time focusing in school?
- What kinds of things distract you in school?
-  Do you have a difficult time making a decision?
-Describe to me your process of making a decision.
-  Do you understand the difference between right and wrong?
-  Do you have a difficult time remembering things?
-What are some things you do to help keep track of things in your life?
-  Do you have a difficult time becoming motivated?
-What are some things you do to stay motivated?
 Describe to me what would you do if a friend from school invited you to go to the
mall with her after school, but you were already planning on going home and taking
a nap?
 What would you do if you had to study for an upcoming test, but reruns of your
favorite show were on?
 What are some ways that help you focus in school?
 What are things that you do to help keep yourself motivated and accountable?
 How do you handle being in situations when you have to choose between right and
wrong?
Spiritual: 
I’m going to ask you a series of question and I want you to answer by saying “never,”
“sometimes,” or “always” and why you answered the way you did.
1- Never
2- Sometimes
3-Always
-  I feel like I have a purpose in life. 
-In what ways do you feel is your purpose?
-  I feel like I am at peace.
-What are some ways you find to bring peace to you?
-  I feel like I am living at my full potential.
-Describe to me what you think is your full potential?
-  I know who I am.
 What does it mean to you to be spiritual?
 What are activities that bring you the most peace?
 Why do you think it is important to feel like you have a purpose in your life?
Recreation:
 What do you know about leisure?
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 What do you consider leisure?

 What do you like to do in your free time?
 What activities do you and your family participate in?
 If you had the opportunity to do anything right now, what would you choose to do?
 What types of activities did you participate when you were younger?
Limitations/Barriers to leisure: 
 What do you feel like stops you from being happy?
 Do you feel like you have the opportunities at home to participate in leisure?
 What do you wish you had in your life that would help make you happy?
 How do you wish things were different?
Strengths/Recreation abilities: 
 What do you see as your strengths?
 What do you like about yourself?
 How do you think your friends and family would describe you?
Patient Expectations: 
 Where do you see yourself at the end of our time together?
 What expectations do you have for me as your therapist?
Conclusion: 
You have done an excellent job answering these questions. Are there any questions you have for
me before we end here today? I will be in contact with you within the next couple of days to
discuss your treatment plan. Thank you for your time.