You’re an OT working in a hospital setting and you’ve just got a new referral to see a client for an initial assessment. Do you know what to ask? How about what content needs to be in your documentation? If you have any doubts that your approach is both client-centred and efficient, then take a read through this blog.

The primary role of an OT in most hospital settings is to facilitate the patients safe discharge, either to their home, or another discharge destination. To do this, we need to have a clear understanding of the patient’s diagnosis, social history, home environment, previous function, current function, and supports required for discharge. If you’re thinking “It would be great to have these all listed out in a form that I could just fill in during the interview” – then I agree, and that’s why I created the Occupational Therapy Hospital Initial Assessment Form. You can download a copy for free here: https://yott.au/hospital_initial_ax_form

To gather all this information, you may need to use a combination of interviewing the patient, observing the patient undertaking functional tasks, and/or contacting someone from their support network for collateral information. Here's a quick summary of what to ask for each section (PS these sub-headings could be used as sub-headings within your initial assessment documentation):

Diagnosis:

• Find out why they were admitted to hospital and consider if it is an acute injury or illness, or something more chronic (where they may have been in and out of hospital a few times, so there could be old OT clinical notes to check out!)

• Make sure you understand the common functional implications of the diagnosis, so you ask relevant questions (e.g. people with renal failure may be receiving dialysis, and that can cause significant fatigue that interrupts their ability to do their daily activities). If you don’t know, look it up or ask!

Social History

• Ask who they live with, and whether they receive any help with self-care or domestic tasks from informal supports, such as family or friends.

• Find out if they normally receive help from formal services, such as home care or NDIS-funded support workers, or find out if they would be open to receiving this type of help if you think they might need it for discharge.

 Home Setup

• It’s important to find out what type of home they live in, and what the access is like, especially if someone has been admitted with changes to their mobility. Do they have stairs to get into their home? Do they have a small little unit and they’re going to find it hard to get around the unit using the four-wheeled-walker they’ve been using on the ward (when usually they use a walking stick).

• Find out about their bathroom. Not just whether there are grabrails, but is it a big or small shower recess, or is it over a bath? If it is over the bath, is there a screen or curtain? These details make a big difference if you need to make a quick recommendation regarding equipment options that will allow them to sit when showering.

 Previous Function

• Cover all the obvious essentials – mobility, transfers, and self-care tasks. Then, cover the less obvious such as managing medications and finances if it will be relevant to their discharge.

• Find out about how they managed their domestic tasks, but don’t forget other productivity tasks such as driving and work (you’ll be surprised how important these questions end up being sometimes!).

Current Function

• Cover all the obvious essentials of mobility and self-care again, but this time it is helpful to do an observational assessment, not just interview. This could include observing functional mobility, like how they get in and out of bed, or on and off their chair or toilet.

• Even though most patients won’t be completing domestic tasks while they’re in hospital, find out what their plan might be for discharge, and whether there are any concerns that they will be able to manage. If there are, make sure you let the social worker know early so they can help with arranging appropriate supports.

Other Important Issues to Consider:

• Depending on the client’s diagnosis, or the caseload you’re working in, there may be some extra issues you need to ask about or assess, as they generally impact the patient’s function.

• This could include: upper limb function, cognition, sensory issues (vision/hearing), falls history and pressure care needs.

Patient Goals:

• Once you have gathered all this information it is important to ask the patient what their concerns or plans for discharge are. Are they keen to leave ASAP? Are they wanting extra help or equipment? Are they worried they won’t manage at home at all?

• It is important you acknowledge their concerns and allow them to be active collaborators in the discharge plan!

Plan:

• Now you have all the info, it’s time to make a plan. Is the patient ready to go, or do they need to improve their function further first? Are they functionally at their baseline, but they need some extra equipment and services to be safe? Do they need to see some other team members such as a social worker or physiotherapist before they are ready to go?

• Clearly document whether the patient is safe for discharge or not, what needs to happen before they can be discharged, and make any referrals ASAP. Then get cracking on whatever the next stage of the OT process is for your patient.

Initial assessments are an extremely important part of the OT role within a hospital setting. With a systematic approach, such as using data collection forms or documentation templates, you can develop this skill and play a crucial role in ensuring your patient is discharged quickly, but also as safely as possible.

If you found this blog helpful, then sign-up to the Your OT Tutor mailing list to be notified when new resources, courses, and blogs are available.

#occupationaltherapy #students #clinicaleducation #hospital