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Assessment and Goal Setting

This page sets out the guiding principles by which Occupational Therapists will complete their assessment of children and set goals as a result of the assessment.

Statement 1

Occupational therapists will make contact with the client and/or family within 7 working days of allocation.

Occupational therapists will carry out assessment and plan intervention within 35 working days from allocation.

Statement 2

Occupational therapists should prepare for an assessment by ensuring that it is appropriate, and that the child being assessed or their representative has given their consent.

Occupational therapists are required to:

  1. Identify the need for assessment, based on information provided upon referral.
  2. Explain the nature and purpose of the assessment to the client and/or their representative to facilitate their involvement.
  3. Establish, develop and maintain effective communication with the client.

Statement 3

A decision not to carry out, or to discontinue assessment should be based on identifiable and justifiable reasons.

Occupational therapists are required to:

  1. Only assess when it is in the remit of the service, in the scope of their competence and when it does not pose a risk to the safety of the client or therapist.
  2. Document any decision not to assess and the reasons behind it.
  3. Inform the referral source when an assessment is not carried out following a referral.
  4. Recognise situations when the assessment process should be discontinued.
  5. Document any decision to discontinue an assessment and the reason behind it.

Statement 4

The assessment tool should be fit for purpose, and should be used appropriately by the Occupational Therapy Service, ensuring that the staff member has the appropriate skills and knowledge required.

Statement 5

The assessment should be carried out under conditions that recognise and value the needs of the client and their main carer/s.

Occupational therapists are required to:

  1. Ensure the assessment accepts and values the background and culture of the client.
  2. Ensure the assessment is undertaken in the client's preferred language.
  3. Ensure privacy and confidentiality by undertaking the assessment in a suitable environment.
  4. Ensure assessments are centred on the client, taking into account their occupation, role, environment and lifestyle.
  5. Assess occupational performance in relevant areas, including self care, productivity and leisure.
  6. Assess cognitive, affective and physical components related to the occupational performance issues identified.
  7. Assess the elements of the environment and their impact on the occupational performance.
  8. Integrate and analyse assessment findings.
  9. Make the outcome of the assessment available to the client and/or their representatives (with the individual's consent).
  10. Provide an opportunity for the client and/or their representatives to comments upon the assessment.
  11. Recognise the rights of the client's main carer/s to an assessment of their own needs and make appropriate referrals if required.
  12. Document the carer's needs and abilities and any referrals made on behalf of the carer.

Statement 6

The goals for intervention should be agreed in discussion with the client and/or their representatives, based in their priorities and the needs as indicated by the assessment.

Occupational therapists are required to:

  1. Record clearly the client's assessment needs and goals and objectives of intervention.
  2. Agree priority areas for intervention with the client.
  3. Record clearly the client's priorities and choices.
  4. Work in partnership with the client and their representatives when identifying goals for intervention.
  5. In collaboration with the client, prioritise targeted outcomes.
  6. Develop measurable and obtainable objectives which define the way to achieve the targeted outcomes.
  7. Communicate the outcome of the assessment and the identified intervention goals with the other core members of the health and social care team.

References

Assessments procedure

TaskProcessAppendixForm (location)Notes / Contact infoTimescale
Framework for AssessmentGeneral SS assessment needs to be completed if new child to team. Special Needs Appendix can be used.  OT may choose to use specific OT assessments detailed below See main team procedure file. Copies held in reception. Initial (Child in Need) Assessment: Special Needs Appendix CH:6/SNSee appendix 3.1 and 3.2Initial (Child in Need) Assessment should have been completed prior to allocation to OT7 days from referral.
OT Assessment FormThorough assessment of environment, and all ADL at home, school and respite3.1*Held in OT Shared file (computer) in "case notes"Adapt as necessary/helpful.Completion with Action Plan within 35 days
Specialist OT Report FormComplete form as part of whole assessment/or on its own.3.2* Useful written record of assessment summary, clinical reasoning and recommended outcome. 
Specialist OT Risk Assessment Moving & HandlingComplete most relevant form as part of overall assessment or on its own3.3Shells of 2 assessments held in OT shared file in  Moving & HandlingAdapt as necessary/helpfulCompletion as part of full OT Assessment with Action Plan within 35 days
Risk Assessment (generic) 3.4Risk Assessment See H & S manual on intranetUse associated guidance notes 
Specialist Assessment to be used as appropriate PEDI, PEGS, CDPMConsult assessment manuals for administration and scoring procedure Held in back OT office  
Adaptation AssessmentSee 'Framework' in appendix as guidance for assessment. May clarify 'assessed need' prior to completing SoN for DFG or be useful if seeking alternative funding.3.5   
CarersComplete form Carers Assessment Form (Parent/Carers of disabled children) Cabinet in reception