How to perform an OT screen for adults - video tutorial and forms! | #occupationaltherapy #OT #SNFOT #HomehealthOT #OTtreatmentideas

How to Perform an Occupational Therapy Screening (For Adults!)

I get asked all the time about how to perform a quick and easy occupational therapy screening to help decide if a referral is necessary for skilled occupational therapy services for adults.

I gotcha! and wanted to share one of the educational videos on this topic from the Seniors Flourish Learning Lab titled "How to Perform an Occupational Therapy Screening," as this is one of the questions that members had and all treatment ideas, resources, handouts, etc are created directly from member requests!

What is an Occupational Therapy Screening?

An OT "screen" 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 OT service.

How to perform an OT screen for adults - video tutorial and forms! | #occupationaltherapy #OT #SNFOT #HomehealthOT #OTtreatmentideas

Typically I Complete a Short Chart Review and Specifically Look at:

  • level of function at admission
  • current pain scales
  • functional level charting (and if it has changed recently)
  • talking 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
  • falls
  • w/c positioning
  • splinting/ROM changes
  • w/c management
    • do they need a power mobility?
    • are they able to perform functional mobility independently?
  • ADL
  • weight loss: feeding/eating difficulty
  • cognitive changes affecting occupational performance
  • wounds/skin
    • it's impact on 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?

How to perform an OT screen for adults - video tutorial and forms! | #occupationaltherapy #OT #SNFOT #HomehealthOT #OTtreatmentideas

In 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, even though the CMS regulations on this is not clear.

I have developed an OT Screen Form that is a part of the Learning Lab resources (under Assessments -> Clinical) to make the entire process a little easier.

What do you include in your OT screens?

Comments 9

    1. Post

      Hi Monica

      Currently, the OT Screen Form is a members only perk as a part of the Membership. If you are interested in all our membership resources and downloads, check it out here!

  1. Can this also be applied in an outpatient setting? I’ve had a lot of difficulty researching how appropriately to perform a screen – especially with the adult and geriatric population, there’s TONS of information for school based but nothing really for outpatient. As a new grad who just got hired at a company that does not have any other OT’s, I’m struggling to find the best format in which I can ask the relevant questions. Screens aren’t something that are really discussed in school – more so skimmed over. I’m not entirely sure what I should and should not be asking. Thanks for any help!

    1. Post

      Madison, are you talking more about an evaluation form vs a screening form? Typically a screen is for when you are not sure if they are appropriate for services and from my experience, you are getting a direct referral in outpatient.
      Is it different where you are?

      Happy to lead you in the right direction!

  2. Can you explain further what it means of the “3 days” of documentation, with your screen to actually pick them up and do an evaluation? I’m a new OT practitioner and internationally trained working in a SNF/nursing home facility

    1. Post

      Hi Tom. Regardless if we “screen” a client and we see a skilled need for OT services, many facilities also need documentation from CNA/RN, etc that these are areas that the client is having difficulty with. So, that being said, sometimes if they do not have it documented (even if they are seeing it has been an issue with the client – meaning poor documentation on their part), there needs to be a few days of them really putting that in their notes that this is a problem that needs to be addressed.

      Example: you screen a client and they are complaining of pain because they are laterally leaning in their ill fitting wheelchair. You talk to the cna staff and they say “yes, Mr. X has been complaining about this for a few weeks now and I can’t get him to sit up in his wheelchair.” You go to the chart to see if this has been documented by CNA/RN/LPN and you see nothing. You talk to the nurse and they say “yes, he has been having trouble with this lately.” Some facilities need the RN to document for “3 days” or whatever their protocol is to state in their notes that this has been a problem – not that you just see this during your screening process.

      1. Another good reason for 3 days of documentation before picking up on caseload, for instance in a case of pain, did they just sleep wrong last night and in 2 days the pain is better. It also lets surveyors know there was a validated reason for evaluation

    1. Post

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