4 weeks down - a little about evals

I just finished my 4th week at the rehab center! I'm still really enjoying it and learning a lot. I have now gotten into doing evaluations on the new patients which I really like! I have done 2 this week! At the facility we only get 15 min for each evaluation and here is how we go about them for most of the pts I have seen thus far

1. Intro self and purpose of Occupational Therapy
2. Assess their cognitive status: judgement, insight, safety awareness, orientation (x4), problem solving, memory etc..  Do this by asking questions (address, what happened to bring them to the facility, their bday, where they are, what day of the week it is etc..).
3. Pain- rate it on a scale of 1-10
4.  Endurance- note any shortness of breath after activity
3. UE ROM and Strength.
4. Functional Mobility: bed mobility, transfers sit-stand onto/off the toilet, into/out of w/c, whether they walk indep, use a walker or w/c. sitting/standing tolerance and balance.  Include level of assistance with transfers,
5. ADLs: UB dressing/bathing, LB dressing/bathing, toileting, eating/feeding,  include level of assistance for each ADL
6. IADLs: meal prep, shopping, cleaning.... most of our pts are dependent for IADLs at eval status..

After the evaluation portion is over, the pt is taken to the rehab gym for their first session- which is usually pretty short just to ease them into it.

This is just one what to organize an eval....of course there will be many other components for more complex patients such as sensation (2 point, pain, temperature, touch), vision, trunk control, reflexes etc..

I find this outline really helpful to go by when evaluating patients (esp ortho and cardiac pts like I have been seeing).