details

Overview

Service Initiation
Consent
Assessment
Analysis and Recommendations
Record Keeping
Disclosing Information

Introduction

Assessments are an integral part of occupational therapy practice. Assessment is defined as “the process of gathering sufficient information about individuals and their environments to make informed decisions about intervention.”¹ It serves as the foundation for an occupational therapist’s decisions, professional opinions, interventions, and recommendations. Assessments can incorporate standardized, non-standardized, and informal assessments. and other data gathering sources. Assessment is an ongoing process throughout service delivery and is to be completed with clinical changes or as new conditions arise.

The College uses the term “client” to refer to the individual(s) who receive occupational therapy services from an occupational therapist. Under the Regulated Health Professions Act, 1991, the term “patient” is used to refer to the recipient of health care service provided by a regulated health professional. For the purpose of the Standards for Assessments, the term “client(s)” is used; this term is also used in reference to “patient(s)”.

The scope of occupational therapy is broad. Some occupational therapists work as solo practitioners, while others may function within multidisciplinary or interdisciplinary team-based environments. The type and format of assessments may vary due to many factors including: the purpose of the assessment, service delivery model, practice setting, and available resources. All assessments involve a comprehensive, consistent, and collaborative process. Occupational therapists are expected to apply evidence-informed relevant and current practices throughout the assessment process, and draw on their knowledge, skills, judgement, and experience to determine the most suitable approach.

This means that the approach used to conduct assessments can differ between individual occupational therapists depending on the client’s physical, social, cognitive, emotional, behavioural, environmental, spiritual, cultural and communication needs.

The Standards for Assessments reflect the most common approach to assessments conducted virtually or in-person and are based on core occupational therapy principles outlined in the Essential Competencies of Practice for Occupational Therapists in Canada, 3rd edition. The purpose of these Standards is to ensure that occupational therapists in Ontario are aware of the minimum expectations for the assessment component of their practice.

¹ Christiansen & Baum, 1992, pg. 376.

Application of These Standards

The following standards describe the minimum expectations for occupational therapists.
The performance indicators listed below each standard describe more specific behaviours that demonstrate the Standard has been met.
It is not expected that all performance indicators will be evident all the time. It is expected performance indicators could be demonstrated by the occupational therapist if requested.
There may be some situations where the occupational therapist determines that a particular performance indicator has less relevance due to client or environmental factors. Such situations may call for the occupational therapist to seek further clarification.
It is expected that occupational therapists will always use their clinical judgement to determine how to best complete the assessment based on the scope of the referral and specific client needs.
It is expected that occupational therapists will be able to provide a reasonable rationale for any variations from the Standard.

In the event of any conflict or inconsistency between these Standards and other College Standards, the Standard with the most recent issue or revised date prevails.

College publications contain practice parameters and standards that all occupational therapists practising in Ontario must utilize in the delivery of service to their clients and in the practice of the profession. They are developed in consultation with occupational therapists and describe current professional expectations. These may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.

Pursuant to the Regulated Health Professions Act, 1991 (RHPA), the College is authorized to make regulations in relation to professional practice. The College’s Professional Misconduct Regulation establishes that “contravening, by act or omission, a standard of practice of the profession or failing to maintain a standard of the profession” constitutes grounds for professional misconduct.

Service Initiation

Standard 1

The occupational therapist will screen the referral and gather sufficient information to determine whether to proceed with the assessment.

Performance Indicators

An occupational therapist will:

1.1

Determine who is/are the client(s);

1.2

Gather and review client information that the OT is permitted to access, or in which the OT has authorization from the client/substitute decision maker (SDM) to gather;

1.3

Determine if the assessment falls within their specific role and scope of practice;

1.4

Determine if they have the required knowledge, skills and judgement needed to deliver the service;

1.5

Recognize, prevent, and manage any actual, potential, or perceived conflicts of interest;

1.6

Have sufficient knowledge of the legislation, regulatory and organizational requirements relevant to their area of practice and method of service delivery;

1.7

Following screening, notify the client/SDM, referral source, or other stakeholders, whether it is appropriate to proceed with the assessment; cognize, prevent, and manage any actual, potential, or perceived conflicts of interest;

1.7.1

If not proceeding, explain the rationale and provide alternatives where available.

1.7.2

If proceeding;

Communicate the scope and timeframes of the assessment and the required next steps;
Clearly explain their role and responsibilities;
Validate information and make reasonable efforts to ensure the accuracy of the information collected from other sources;

1.8

Determine if it is safe to proceed with the assessment (if virtual or in-person) and manage any identified barriers or risks;

Consent

Standard 2

The occupational therapist will ensure the necessary consent is obtained from the client/SDM in accordance with the Standards for Consent.

Performance Indicators

An occupational therapist will:

2.1

Follow a process to determine client capacity to consent and participate in the assessment, as outlined in the Standards for Consent²;

2.2

Obtain consent for the assessment, discussing the following with the client/SDM where appropriate:

The scope of the assessment,
Confirming any financial arrangements specific to the assessment,
The purpose and nature of the assessment including whether information will be obtained from other individuals,
The legal authority, if appropriate, given to an occupational therapist (for example a court ordered assessment) to conduct the assessment,
The identity and professional qualifications of any individuals who will be involved in the assessment, (e.g., other team members - social worker, case manager),
The potential benefits and limitations of completing the assessment,
The risks associated with completing or not completing the assessment,
The expected process of the assessment, how the information will be collected, used, and disclosed,
The option of the client to withdraw consent at any time during the process;

2.3

Respect client choice not to proceed with the assessment and engage client/SDM in a collaborative approach to understand the implications when withdrawing consent to participate in the assessment;

2.4

Ensure appropriate consent is obtained to collect, use, and disclose personal health information and assessment results including information sharing; unless not legally required to do so;

2.5

Take reasonable efforts to confirm that consent obtained by a third party meets the requirements outlined in the Standards for Consent.

^{2 Standards for Consent (2017);}

Assessment

Standard 3

The occupational therapist will choose and apply safe assessment methods and tools that are client-centred, based in theory and evidence-informed to assess the client’s occupational performance needs.

Performance Indicators

An occupational therapist will:

3.1

Remain current, using relevant evidence and best practice approaches by selecting a theoretical approach, assessment methods and tools that are appropriate to assess the client³;

3.2

Review the properties of the standardized assessment including reliability, validity, and administration criteria to determine the appropriateness of the tool to assess the client

3.2.1

Have the necessary knowledge and skills to administer the assessment tool;

3.3

Manage any risks, contraindications, or limitations of using the selected tools or methods of assessment with the client;

3.4

Collaborate and communicate with the client/SDM and other stakeholders regarding the assessment approach process;

3.5

Gather subjective and objective information and identify the occupational performance issues to be addressed;

3.6

Perform assessments in accordance with the standards of practice and including the Code of Ethics.

³ Townsend & Polatajko (2013). Enabling occupation II: Advancing an occupational therapy vision for health, wellbeing, & justice through occupation.

Analysis and Recommendations

Standard 4

The occupational therapist will ensure they have sufficient information to proceed with the analysis prior to formulating professional opinions and recommendations.

Performance Indicators

An occupational therapist will:

4.1

Using the subjective, objective assessment findings, analyze all relevant information collected;

4.2

Identify any gaps in the assessment findings and determine if there is a need to gather additional information;

4.3

Ensure the assessment represents a fair and unbiased evaluation of the client;

4.4

Analyze the strengths, and challenges of the person, environment and occupation and the impact on occupational performance needs;

4.5

Develop recommendations based on the analysis of the information gathered;

4.6

Consider access and availability of resources when collaboratively setting goals and recommendations;

4.7

Determine the need to make a referral to other practitioners for further assessment;

4.8

Determine if further evaluation is required, if additional information becomes available by the client or other stakeholders following the assessment.

Record Keeping

Standard 5

The occupational therapist will document assessment methods, processes, and findings in accordance with the Standards for Record Keeping.

Performance Indicators

An occupational therapist will:

5.1

Client records are maintained in accordance with the Standards for Record Keeping;

5.2

Documentation is completed in a manner that is accurate, concise, and reflective of the assessment including: consents obtained, sources of information, assessment approach and procedures, results, analysis, professional opinions, and recommendations;

5.3

Documentation complies with timeframes, formats, retention, and destruction established by the standards of practice and processes of the practice setting;

5.4

Data gathered by the occupational therapist and used to inform clinical decisions, which cannot be included or summarized in the record, will be retained (for example drawings or assessment score forms). The occupational therapist will document in the client record or assessment report indicating the existence and location of this data;

Note: Converting data to an electronic format, for retention purposes, is appropriate as long as the integrity and security of the data is upheld.

5.5

Document client participation, and any client tool or environmental limitations associated with the assessment process;

5.6

Assessment documentation is complete and accurate prior to finalizing documents and applying their signature.

Disclosing Information

Standard 6

The occupational therapist will ensure that relevant assessment information is communicated (results, opinions, recommendations) to the client/SDM or relevant stakeholders in a clear and timely manner.

Performance Indicators

An occupational therapist will:

6.1

Communicate assessment results in a timely manner⁴ using terminology that the client/SDM can easily understand;

6.2

Discuss the outcome of the assessment with the client/SDM and provide an opportunity for the client to obtain or provide clarification if requested;

6.3

Confirm client/SDM consent for the disclosure of the assessment information to third party payers/stakeholders unless exceptions apply including those allowed under privacy legislations;

6.4

Provide their professional contact information should there be questions about the OT assessment;

6.5

Comply with current legislation when withholding all or part of the client’s record if it poses a risk of harm to the client or others;

6.6

Ensure the client/SDM is aware of the process to access the clinical record or assessment report;

6.7

Take reasonable measures to ensure that any assessment information disclosed on behalf of the occupational therapist is accurate and represents the occupational therapist’s professional opinion and clinical judgement.

⁴ Timeliness determined by factors such as: the stability/fluctuating status of the client, interprofessional or referral reliance on entries to the clinical record, client/referral source expectations, organizational policies etc.

Reference

Christiansen, C. & Baum, C. (1992). Occupational therapy: Overcoming human performance deficits. Thorofare, NJ: SLACK Incorporated.
College of Occupational Therapists of Ontario (2017). Standards for Consent.
College of Occupational Therapists of Ontario (2012). Guide to the Code of Ethics.
College of Occupational Therapists of Ontario (2011). Essential Competencies of Practice for Occupational Therapists in Canada, (3rd ed.).
College of Occupational Therapists of Ontario (2016). Standards for Record Keeping.
College of Occupational Therapists of Ontario (2017). Guidelines for Working with Third Party Payers.
College of Occupational Therapists of Ontario (2017). Guidelines for Telepractice in Occupational Therapy.
Townsend, E., A., & Polatajko, H., J. (2013). Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. (2nd Edition) Ottawa, ON: CAOT Publications ACE.

Details

Standards for Assessment, 2020

Overview

Introduction

Application of These Standards

Service Initiation

Consent

Assessment

Analysis and Recommendations

Record Keeping

Disclosing Information

Reference