This blog entry will cover adult occupational therapy assessments including The COPM, Berg Balance Scale, MoCA, the Kettle Test, the Nine-hole peg test, ACLS, FIM, and AMPS.
Selecting Occupational Therapy Assessments for Adults
The practice setting and context of occupational therapy for adults vary widely. From geriatrics to physical disabilities, and acute rehabilitation to mental health, client needs, occupational profile, goals, and length of stay will vary greatly. As will the occupational therapy assessments you select. Some settings will call for a very complex evaluation with multiple assessments, while others may only allow for a 15-minute informal screen. Below are selected occupational therapy assessments and tools that can be used with a diverse range of clients.
Canadian Occupational Performance Measure (COPM)
The COPM is sometimes described as an ‘objective-subjective’ test. This may sound like a contradiction but the tool quantifies subjective measures. Here is how it works: The client identifies what they consider to be ‘problem’ areas in their daily lives. The client then rates their performance on a scale of 1-10 and their satisfaction with their performance on the same scale. This provides excellent information about the client’s priorities and is a great tool for collaborative goal planning. As a bonus, the COPM is inexpensive and comes in both paper and digital formats.
Berg Balance Scale
The Berg Balance Scale is another occupational therapy assessment tool designed to provide objective measures to quantify the ability of a client to balance in a variety of scenarios. It is a quick assessment and only requires a few materials: Two chairs (with and without armrests); a stopwatch; a step; a ruler; and a clear area 15ft long. Items the therapist will observe and rank include transfers, picking up an item from the floor, and reaching forward. The scale is easy to score and contains a cut-off score in which clients are at risk of falling. The Borg Balance Scale may also inform the therapist of other performance areas to address.
Montreal Cognitive Assessment (MoCA)
The MoCA is a cognitive screen that takes only about 15 minutes to administer. In that 15 minutes, you will learn about your client’s short-term memory, working memory, attention and concentration, executive functioning, visuospatial abilities, and orientation to time and place. Not only is the paper screen easy to both administer and score, but now there is a MoCA application with automatic scoring. This assessment is an excellent choice for teletherapy evaluations as well.
The Kettle Test
The Kettle Test is unique in that it is a free performance-based test. However, some materials are required, including an electric kettle, kitchenware, ingredients to make coffee and tea, and distractor items. Depending on your client, it will take 10-30 minutes to administer. When the task is broken down, there are 13 points of measurement that are scored on a 4-point scale based on their performance. For example “client turns on the kettle” or “client indicates that they are finished” could be scored high (performed independently) or low (needed physical demonstration or assistance). A nice benefit of the Kettle Test is that it is both functional and honors client choice (the client selects which hot beverage they would like to make).
Nine-Hole Peg Test
The nine-hole peg test is a timed activity that assesses fine motor dexterity. The materials consist only of nine pegs, a peg holder, and a stopwatch. After a demonstration, the client is instructed to use one hand to fill the holes with pegs and then take them out. It only takes a few minutes to teach and administer the test and is generally done on both left and right sides. The therapist uses the time to compare to a list of norms. This assessment is often used for clients with brain injury, Parkinson’s, spinal cord injuries, or other neurological diagnoses.
The Allen Cognitive Level Screen-5 (ACLS)
Another option for occupational therapy assessment is the ACLS. The physical materials of the ACLS include a leather rectangle with holes around the edges, needles, and two different kinds of thread. This screen can give insight into your patient’s functional cognition. By engaging in increasingly complex tasks, your client will learn and problem-solve with and without visual demonstrations. Note for practitioners: If it has been a while since you have administered this assessment, you’ll want to review it and make sure the tool is set up ahead of time. To get accurate results it is important to match the language given by the manual and provide exactly the prompts in the script. While this screen is not an option for telehealth evaluations, a disposable version is now available for settings that have strict infection control procedures.
Functional Independence Measure (FIM)
This widely used occupational therapy assessment measures self-care, transfers, locomotion, social cognition, communication, and bowel and bladder control. Self-care areas that are evaluated include feeding, grooming, bathing, upper and lower body dressing, and toileting. Based on observations, the therapist records the level of assistance needed for each category on a scale of 1 (total dependence) to 7 (complete independence). This information can help therapists track progress, decide on the most appropriate rehabilitation setting, and ensure that the client has the necessary assistive devices to stay safe.
Assessment of Motor and Process Skills (AMPS)
This occupational therapy assessment addresses areas of motor skills and cognitive skills including the ability to sequence, initiate and terminate, and pace one’s self. It begins with an interview so that the therapist can receive background information and ensure that the ADL tasks are relevant to the client. Next, the client decides which functional tasks they would like to perform and the therapist assigns numerical values based on performance. Certification is needed to administer the AMPS. This is achieved by taking a course (online or in-person) and paying an associated fee.
Occupational therapy assessments for adults are as diverse as the clients we serve. Starting at a new place of employment or serving a new population? Ask around to see what other therapists are frequently using and what the facility has access to. What is your go-to OT assessment for adults? Comment below to share!
If you work with both adults and children, you may find our Pediatric Occupational Therapy Assessments blog helpful as well.
Occupational therapy assessments help OTs with developing goals for occupational therapy; linking the found problems and diagnosis with the correct CPT codes for occupational therapy and serving as a base for writing both assessment and SOAP notes.
Pediatric Occupational Therapy Assessments
Pediatric occupational therapy assessments including the SPM, BOT-2, PDMS-2, DAYC-2, Beery VMI, TVPS-4, and SFA will be covered in this post.
Selecting a Pediatric Therapy Measure
There are several choices when it comes to selecting a pediatric occupational therapy assessment or evaluation tool. Standardized and norm-referenced tools are highly recommended both for validity and objectivity. All of the below assessments are both standardized and norm-referenced. When you select a measure for an individual client you will want to consider: Areas of concern; the chronological age of the client; the environmental context; perceived abilities based on caregiver or teacher interviews; and whether the evaluation will occur in person or through a teletherapy approach. For a quick and handy reference, seven pediatric therapy assessments have been described below.
Sensory Processing Measure (SPM)
The Sensory Processing Measure is an instrument that provides a picture of sensory processing as related to an individual child (ages 5-12). A preschool form (SPM-P) is also available for children ages 2-5. The SPM kit comes with two forms: A school form and a home form. Both forms are questionnaires that are designed to be filled out by an adult that frequently observes the child. A parent/caregiver often fills out the home form and a teacher provides information on the school form. The occupational therapist can select either form or they can have both completed analyzing differences in sensory processing between home and school. Both versions of the SPM consider visual, auditory, tactile, proprioceptive, and vestibular processing as well as considerations on how sensory processing impacts the child’s social participation and motor planning.
Bruininks-Oseretsky Test of Motor Proficiency- Second Edition (BOT-2)
This assessment, appropriate for ages 4-21 years, measures gross and fine motor skills. It is used in both school and clinical settings. Occupational therapists often use four of the eight subtests: Fine motor control, manual dexterity, strength and agility, and body coordination. Tasks include copying increasingly complex shapes, cutting, timed activities with small manipulatives, dribbling a tennis ball, and more. These four subtests take 45-60+ minutes to complete. If you are screening a client, there is a “Short Form” that uses select tasks from each category to get a picture of fine motor performance. The BOT-2 is commonly used in both school and outpatient settings.
Peabody Developmental Motor Scales- Second Edition (PDMS-2)
An early intervention staple, the PDMS-2 measures fine and gross motor skills in children from birth to age five. Subtests include reflexes, stationary movement (body control), locomotion, object manipulation, grasping, and visual-motor integration. This pediatric occupational therapy assessment is unique in that it can provide insight into even the youngest of clients. The reflex subtest is designed exclusively for infants up to 11 months. The grasp subtest contains tasks such as holding a rattle, picking up a block, and holding a writing utensil. The visual-motor integration subtest contains tasks such as hand-eye coordination, copying shapes, and copying 3D patterns with blocks. It is important to note that this is a basal-ceiling evaluation. Therefore you will only ask your client to do developmentally relevant tasks.
Developmental Assessment of Young Children- Second Edition (DAYC-2)
The DAYC-2 is another pediatric occupational therapy assessment that is popular in early intervention and is valid for ages birth to six. The DAYC-2 is sometimes delivered as a team assessment and an occupational therapist may deliver this assessment alongside a special educator, speech and language pathologist, and/or a physical therapist. Alternatively, individual professions may focus on one or two relevant domains. There are five domains: Cognition, communication, social-emotional development, physical development, and adaptive behavior. The DAYC-2 does not come with a bag of standardized materials and manipulatives for testing but instead recommends materials from the child’s natural environment. This makes the DAYC-2 a great tool for telehealth evaluations. Simply prepare the caregivers or the in-person provider with a list of criteria for toys to have nearby (for example a board book, and knob puzzles).
Beery-Buktenica Developmental Test of Visual-Motor Integration- Sixth Edition (Beery VMI)
The Beery VMI addresses performance areas of visual-motor integration skills. It is used in both school and clinical settings. The client is asked to draw increasingly complex shapes, starting with a simple line and advancing to shapes with a variety of intersecting lines and angles. The administration is quick and only requires the test form and a writing utensil. The administrator’s manual contains visual examples which help make scoring quick and easy. While there is both a short form (for younger ones) and a full form available, the test is norm-referenced for ages 2-100. By mailing out the response booklet ahead of time, there is also flexibility to deliver the Beery VMI via a teletherapy evaluation.
Test of Visual-Perceptual Skills- Third Edition (TVPS-4)
The TVPS-4 provides a wealth of information about a child’s visual perception skills. Appropriate for ages 5-21 years, the TVPS-4 analyzes skills related to visual discrimination, visual memory, spatial relationships, form constancy, sequential memory, visual figure-ground, and visual closure. The student is provided with a black and white test plate with one ‘visual task’ per page. Depending on the perceptual area, the student may be asked to find a matching image, select an image from a previously shown stimulus, or match an incomplete image. The test takes about 25-35 minutes to complete. Some younger students may benefit from a break accommodation during this test. The TVPS-4 is easy to score and the results can be helpful for intervention and goal planning.
School Function Assessment (SFA)
This assessment is designed to evaluate a student’s performance as related to participation in school. The SFA is in the format of a questionnaire that is provided to the student’s classroom teacher. The teacher then records answers based on their observations of the student. This gives the occupational therapist a picture of how much support the student needs, and their classroom participation and performance. Goals can easily be designed to support a student in their school setting and the involvement of a classroom teacher sets a tone for collaboration. The SFA is designed for students in kindergarten to sixth grade.
Occupational Therapy Goals
Occupational therapy goals and how to create excellent occupational therapy goals; SMART goals; examples of goals with all of the necessary components; and do’s and don’ts for writing OT goals will be covered in this blog post.
You have already conducted a full evaluation of your client. Now it is time to come up with occupational therapy goals for their treatment plan. The next step is to take the data you collected and translate it into meaningful goals to pursue in occupational therapy. If you practice in pediatrics, the goal should also be important to the parent or caregiver. Information about goals comes from the occupational profile, standardized testing, reason for referral, and your analysis of the evaluation. The data you collected in the evaluation serves as baseline data. This will help you track the progress of your client, inform intervention choices, and ultimately give your client a foundation for success.
SMART Goals
A SMART goal is an acronym for a goal that consists of five different essential factors: Specific; measurable; attainable; relevant; and time-based. This is a great tool for occupational therapists and other health professionals when composing goals and checking that each goal contains all of the essential components.
Specific: This section refers to the tangible outcome. What does the client want to do? For example, Laurie will complete a 5-step task of making tea; Aaron will cut out a circle; Mary will wash her hands. Be sure that you know the client’s current level of performance.
Measurable: This piece is essential for both reimbursement and tracking progress. It gives concrete data on the degree of the client’s performance. The measurable piece of a goal can come in many different forms: Duration (within five minutes); pain level (client reporting a maximum pain level of 4/10); portfolio collection (for something tangible the client created); client satisfaction (using the Canadian Occupational Performance Measure). Another important factor to consider: Who will track the data? Sometimes therapist collection of data is sufficient but where carryover is essential, the therapist may want to designate a teacher, health professional, or caregiver to track the data.
Attainable: This is an important area to consider how much time you have with the client along with their current level of functioning. Can the client re-learn to tie their shoes during their short acute care stay? Likely not. However, the same client may be able to wash their hands with a visual aid and no more than one verbal cue.
Relevant: An essential component of occupational therapy, it is important to ensure that your client wants to reach their goals. Motivation can have an enormous impact on progress. While the process of coming up with relevant goals begins when you take your client’s occupational profile, it should be considered throughout the process. If you are unsure, share your goal ideas with your client and ask for feedback.
Time-based: In a written occupational therapy goal this may look like “within five days,” “at the time of discharge,” or “by April 1st, 2022.” The time given will vary by clinical setting. In an acute care setting, goals may be written for three days. Inpatient rehab goals could be several weeks long. In the educational system, students who have an IEP often have goals written for an entire year.
Examples of SMART Occupational Therapy Goals
By June 15, 2022, given one verbal cue and environmental set-up by the therapist or caregiver, Joseph will prepare a cup of coffee, as measured by his ability to complete the task in 4/5 attempts.
By September 30, 2022, given adaptive paper, Kate will correctly sequence letters with 80% accuracy in 3 out of 4 consecutive trials, as measured by portfolio collection.
By January 3, 2022, to demonstrate improved bilateral coordination and self-care skills, Brandon will don and doff shoes independently in 4/5 trials, as measured by the caregiver report.
The Do’s and Don’ts of Occupational Therapy Goal Writing
• Don’t write a goal that you do not have baseline data for. Without this foundation, you will not know what criteria to add for your client or if the goal is attainable or even necessary. This would also provide a significant challenge for writing progress notes.
• Do consider their prognosis when selecting goals. Criteria for an otherwise healthy client recovering from a hip replacement will vary greatly from a client who is living with chronic multiple sclerosis.
• Don’t assume that an ADL or IADL is meaningful to your client. While a grocery shopping goal can encompass many of the skills that your client is working on, they may greatly prefer to order their groceries to be picked up.
• Do consider goal-writing exceptions for Individualized Family Service Plans (IFSPs). Since in this practice setting, the family unit functions as the client, goals are often written to be simplified. For example, a goal may be measured on whether the child completed a task or not.
• Don’t put in more than one measurable objective. This is a common mistake that makes tracking goals more challenging than necessary. Instead, make sure you prioritize and then separate important goals into unique objectives. For example, rather than “use a dynamic tripod grasp to draw a 5-part person” create one objective for grasp and another objective for visual motor skills.
• Do create a system for tracking data over time. This may look like a visual representation on graph paper or computer software that automatically generates a visual as you input numerical data.
Starting an Occupational Therapy Private Practice
Starting your own occupational therapy private practice requires a broad base of knowledge. You’ll need to understand business planning, legalities, insurance and credentialing, manage administrative needs, strategically choose a practice location, market your practice and establish mentorships.
If you’re a business-savvy occupational therapist wanting to contribute to your community by helping meet unmet needs, an occupational therapy private practice may be for you. Depending on the services provided, one OT private practice may look and operate completely differently than another. However, several essential components are necessary to get underway.
Business Planning
The first step is often to consider your vision for your occupational therapy private practice. What population do you want to serve? Will you be utilizing direct service, consultation, or something else? A market analysis can be a useful tool in business planning as it can:
- Provide facts that will help you analyze whether your services are appropriate for the community.
- Help you understand the population you are intending to serve alongside community demographics like average age and income and population density.
- Define direct and indirect competition and whether another occupational therapy private practice is already meeting the needs of the community you are looking to serve.
All of this can be summed up in a SWOT analysis. SWOT is an acronym that stands for strengths, weaknesses, opportunities, and threats. SWOTs help you consider finances, location, and available resources to create an overall picture of where you stand on beginning your occupational therapy private practice. Therapists can conduct a SWOT analysis in the early stages of transitioning to an occupational therapy private practice.
Legalities
Rules regarding starting a business (such as occupational therapy private practice) will vary state-by-state. The Small Business Association and your local or national occupational therapy associations can be excellent resources. You will need to maintain your occupational therapy license and fulfill any continuing education units that your state requires. A private practitioner will need professional liability insurance to protect both you and your clients. All communications must always be HIPAA compliant.
Get Credentialed
Many clients will be interested in paying for services with their medical insurance. To get reimbursed, you will need to join insurance provider panels. This can take several months and you will only be able to apply to panels that are accepting occupational therapists in your geographical area. The Council for Affordable Quality Healthcare, most often known as CAQH, provides a comprehensive initial application that is used by several private payors. This is often the first step in becoming credentialed by third parties and is a good place to start. While you go through the often lengthy process of credentialing, consider accepting private pay, HSA/FSA, or a sliding-scale system to start filling your schedule. Accepting a variety of payment methods in your occupational therapy private practice is important because it makes your services accessible to more clients.
Find a space…. Or not!
Several private practice OTs do not have a physical location when they begin. Many opportunities are available to be an independent clinician without an actual clinic space. This includes home health across the lifespan, telehealth, and independent contracting. Other therapists join together to share space among a variety of health professionals.
If you are ready for your own space to treat clients, several considerations should be addressed when selecting the perfect practice location. The occupational therapy private practice office should have a waiting area that allows you to comply with HIPAA regulations in addition to:
- A safe area outside
- A clean bathroom; and
- Adequate privacy for more than one client in the clinic at once.
Accessibility is also critical within our practice field and basic American Disabilities Act compliance should be considered. Examples include:
- Ramps
- First-floor access or an elevator
- Bathroom accessibility
- Wide aisles to navigate the space
- Handicap parking
Marketing is how you’ll get out the news about your new occupational therapy private practice. If you made a thorough business plan you will already have an idea of what clients and referral sources you will need to target.
Logos: Create a recognizable logo with your practice name which can be used for printed advertisements, signage, social media, business cards, and more.
Networking: An especially effective way for occupational therapists to market is by becoming involved in the community. Speak at conferences, join the local chamber of commerce, and arrange a time to meet with referrers to introduce yourself and the services you provide.
Word of mouth: Of course, providing consistently excellent services to your clients is a great way to get free marketing by word-of-mouth.
If providing telehealth occupational therapy services, you may find this free teletherapy e-book useful. It covers everything from setting up your office for telehealth to marketing your teletherapy services.
Connect with a Mentor
Navigating your occupational therapy private practice for the first time can be challenging. Rules and legislation are fluid and vary between states. If possible, connect with a mentor who practices in your state. They can connect you to resources, and networking groups, and answer questions that you will inevitably run into.
Policies and Paperwork
Paperwork is a significant endeavor for an OT transitioning to private practice. Clearly defining policies and keeping track of your documentation, consent forms, referrals, invoices, and other paperwork gives you credibility and a professional edge. Define expectations for your clients (will you charge for no-shows?) and any therapists you may hire. Organization and selection of a system that works for you as a practitioner are essential. An EHR system can fill in this need. TheraPlatform is an all-in-one system that includes the ability to schedule, document, submit insurance claims, allow the client to fill out forms, conduct telehealth vis the rebuilt-inn video conferencing,g and more.
Occupational Therapy SOAP Note
Occupational therapy SOAP note, an overview of SOAP notes; questions to ask when writing each section; the do’s and don’ts of writing soap notes; the benefits of using SOAP notes in occupational therapy; and an example of an occupational therapy SOAP note will be covered in this post.
The SOAP note method of documentation can be an excellent fit for the occupational therapy profession. Why does it work well for OTs? We are always looking at the big picture. SOAP is an acronym that stands for subjective; objective; assessment; plan. These are all important components of occupational therapy intervention and should be appropriately documented. Using a SOAP note format will help ensure that no essential element of therapy is left undocumented.
When composing an occupational therapy SOAP note, questions to ask yourself may include:
S: Subjective
What is the client reporting?
What are the client’s parents or caregivers reporting?
Is the client reporting pain?
Are they complaining of fatigue?
O: Objective
What level of assistance did the client need?
How many verbal and physical prompts were provided?
What did you observe?
How did you grade the activity or modify the environment?
In what percentage of trials was the client successful?
What progress is the client currently making on their goals?
A: Assessment
After examining the subjective and objective data, what does this mean about your client’s progress?
Why did you select a certain intervention activity?
Have there been any significant changes in functioning?
P: Plan
Should the treatment plan be changed? How?
Does a new referral need to be made?
Are any accommodations or modifications recommended?
The Do’s and Don’ts of occupational therapy SOAP Notes
• Remember, the SOAP acronym isn’t completely exclusive when it comes to what you need in your documentation. Do remember to the patient’s name, date of birth, date and time of the service, as well as your credentials and signature.• Do use the SOAP note format in order. It is commonly recognized by a variety of health professionals. Following the standard order can help your interdisciplinary team find the information that they need, fast.
• Don’t put your observations or assessment into the subjective section. The subjective category is a way to capture your client’s voice, perspectives, and goals.
• Don’t neglect to provide quantitative data. This will help you select future interventions and keep track of patient progress.
• Do include justification that the services are medically necessary. This is essential for reimbursement by third-party payers.
• Don’t copy and paste. While some of the information may look similar from session to session, it is disadvantageous to leave out specific data from a given session. Accurately document your client’s progress by ensuring that each SOAP note is unique to that therapy session.
Benefits of Occupational Therapy SOAP Notes• SOAP notes can be beneficial in the event of an insurance audit. The narrative format helps capture a unique session and each SOAP note should be distinct. The subjective data especially helps to verify that the therapy session occurred.
• A complete SOAP note should clarify the skilled processes of occupational therapy. In addition to adding credibility that the session happened, in the event of an insurance audit auditors will be looking for skilled intervention. This will be covered in your assessment section.
• Managing a large caseload? SOAP notes make a great tool for intervention planning. When planning an upcoming session you will look at your previous SOAP note to determine your plan. At this point, you will have already used your clinical reasoning to make an assessment and plan for the upcoming session.
• SOAP notes helpwith writing progress and discharge notes. With the narrative form of a SOAP note, you can easily access quantitative and qualitative data that relate directly back to functioning.
• SOAP notes are a commonly used format among health professionals and are meant to be short and succinct. This can help you or another healthcare provider quickly and easily find the information that is needed.
SOAP Note Example in Occupational Therapy
Here is an example of the occupational therapy SOAP note. This client has two goals. Briefly: Crossing the midline while participating in functional activities at school and using a functional grasp with a variety of writing utensils.
S: Upon entering the clinic, the client stated “I just woke up and am very tired.” The caregiver reported that the client is using his right hand about 70% of the time and switching to his left hand the rest of the time.
O: The client demonstrated a digital pronate grasp in 80% of opportunities and a violin grasp with all four fingers on the writing utensil in 20% of opportunities. Movement for coloring was generated from the client’s elbow and shoulder. The client uses his left hand with more frequency when the writing utensil is placed on his left side. The client fell out of his chair three times during the session and supported his neck with his hands while his elbows were propped on the table. He rested his head on the table on four occurrences. Physical (1) and verbal prompts (1 in 50% of trials) are needed for crossing the midline.
A: Hand dominance is still emerging and hand preference is often selected based on where the materials are (i.e. If the client has to cross the midline). The client demonstrates a lack of proximal stability and postural control. This is contributing to difficulty isolating the smaller muscles of the hand for a functional grasp and therefore the ability to fully participate in coloring activities at school.
P: Provide midline crossing education and activity ideas to caregivers and teachers. Continue with OT 1x per week for 60 minutes to address midline crossing with fading physical and verbal cues as well as grasp. Monitor postural control and refer to PT if lack of stability persists. Provide the client with short utensils to promote emerging grasp.
Summary
Occupational therapy private practice can be a fulfilling way to make a difference in your community. Coming up with a solid plan, accepting a variety of pay sources, making connections, and being consistent and organized can help you reach success in your new endeavor.
