Occupational Therapy Screening Form and Instructions
Because I get questions about how to do a “screen” all the time from OT practitioners and level II fieldwork students, I decided to share this information and quick micro video typically exclusive to OT Flourish Members.
What is a screen?
It is a “hands-off” look to identify a patient’s needs and possible rehab potential with the determination to see if they would benefit from skilled OT services.
You may be requested to do a screen because it is a “quarterly” screen (in a nursing home setting) or referral for screen from staff/other disciplines/MD to see if a prescription would be appropriate.
They can take a lot of time while you are learning, but trying to be efficient is key. Mine typically take no more than 15 minutes. You are not evaluating them, but seeing if they would benefit from SKILLED service.
Complete a short chart review and specifically look at/do:
- level of function at admission
- current pain scales
- functional level charting (and if it has changed recently)
- talk to the staff and/or referral source (CNAs have SO much knowledge about the patients/residents functional ability and difficulties)
- ask the patient directly what they are having trouble with and if they have noticed any changes in:
- function
- more staff assistance
- pain
- skin integrity
- mobility
Most common things to pick a patient up for skilled OT service through a screen include:
- pain
- w/c positioning
- splinting/ROM changes
- w/c management
- do they need a power mobility?
- are they able to perform functional mobility independently?
- ADL
- weightloss: feeding/eating difficulty
- wounds/skin
- transfers, use of equipment, positioning, etc
- do they need a restorative nursing program established (in nursing home setting) or does the program need to be modified to pt’s current needs
In a nursing home setting:
- If you think it is appropriate to “pick them up,” you must make sure that there is nursing/CNA documentation that they have had a decline in the area that you are seeing
- Many facilities require “3 days” of documentation, with your screen to actually pick them up and do an evaluation.
The OT Screen is quick checkbox format that helps you provide a comprehensive screen and document both the need or no need for skilled OT services.
