Standard for Assessment and Intervention
Occupational therapy includes all aspects of assessment, intervention, and consultation. Assessments are the foundation for occupational therapists’ professional opinions and the interventions they recommend. All assessments and interventions are to involve a collaborative approach with clients where their occupational needs and preferences are prioritized when possible.
Occupational therapists are expected to:
1. Screen the request for services
1.1
Gather enough information to decide whether to proceed with services, including considering any conflicts of interest.
1.2
Compile client information only with consent.
1.3
Understand the laws, rules, and organizational policies relevant to the area of practice and method of service delivery.
1.4
Carefully consider the social, ecological, and economic implications of care.
1.5
Decide whether it is safe to proceed with the services and what method of delivery is best (for example, in-person or virtual).
1.6
If it is not appropriate to proceed, explain the rationale to the client, the referral source, and any other professionals, partners, and interested parties. Discuss any alternatives available.
1.7
If it is appropriate to proceed:
- Clearly explain the occupational therapist’s role and responsibilities
- Clearly explain the scope and time frames of the services and the next steps
- Follow the Standard for Consent
- Make reasonable efforts to ensure that referral information remains accurate, including any details collected from other sources.
2. Assess clients within the scope of the services requested
2.1
Co-create an assessment process with clients that is culturally safer, is accessible, and will assess their occupational participation and needs.
2.2
Select assessment methods and tools that are most suitable for clients and that consider the scope of services, using current theories, relevant evidence, and best-practice approaches.
2.3
Know the properties of standardized assessments, including reliability, validity, and administration criteria. Have the knowledge, skills, and required training to administer any assessment tools used.
2.4
Manage any risks or limitations to using the selected assessment tools and methods with clients (for example, communication needs, culturally sensitive practices, and physical impairments).
2.5
Apply culture, equity, and justice considerations throughout the assessment process.
2.6
Collaborate and communicate with clients, other professionals, partners, and interested parties to support evidence-informed decision-making.
2.7
Within the identified circle of care, collaborate and communicate with clients and others to obtain relevant information and gather collateral data to identify the occupational participation challenges and goals to be addressed.
3. Analyze assessment findings and recommend the services needed
3.1
In formulating professional opinions and recommendations, identify any gaps in the assessment findings, and decide whether additional information is needed, including assessments by other health professionals.
3.2
Ensure that assessments represent a fair and balanced evaluation of clients. Consider assessment findings with all other relevant information collected. Analyze findings and outline recommendations in the context of each client and their specific situation.
3.3
Analyze clients’ strengths, challenges, contexts, and occupations and the impacts these have on occupational participation.
3.4
Develop evidence-informed recommendations based on the analysis of the information gathered.
3.5
Work with clients to develop context-specific occupational therapy goals, including determining whether the services of other professionals are required.
3.6
Should additional information become available following assessment, decide whether re-evaluation is required.
4. Develop and implement the occupational therapy plan
4.1
Work with clients to co-create and develop personalized intervention plans. Each plan must include the client’s understanding of their health, well-being, and recovery. Plans must keep clients’ occupations at the centre of practice.
4.2
Take into consideration the resources that are available and accessible for proceeding with the services proposed.
4.3
Confirm that clients understand occupational therapy plans. Review and evaluate plans regularly in partnership with clients, and change plans as needed. Plan and discuss the setting or resetting of goals, service transitions, and discontinuation.
4.4
Follow the Standard for Consent throughout service delivery.
4.5
Collaborate with other professionals to navigate shared or overlapping roles and responsibilities.
4.6
Be clear about the roles and responsibilities of the occupational therapist if supervising other individuals in delivering services.
5. Communicate assessment and intervention information effectively
5.1
Be clear and timely when communicating assessment and intervention information, such as results, opinions, recommendations, and updates. Use terms that clients and other professionals, partners, and interested parties can understand. Allow time for asking and answering questions.
5.2
Document all services per the Standard for Record Keeping.
5.3
Provide business contact information in case questions arise later.
5.4
Comply with current legislation if it is necessary to withhold any assessment or intervention information that poses a risk of harm to clients or others.
5.5
Ensure that clients are aware of the processes to access their record or assessment report.
