![]() Occupational Performance I would typically write up the assessment as follows: assessment : montreal cognitive assessment ( moca ) (write assessment name out in full) Form is filed overleaf / in rear of notes etc. Family perspective This can be helpful is much of the information that s given is from family or contradicts what the patient reports to you, or if the family have specific concerns about the patient.ĥ Disclaimer: the above material is purely for teaching purposes and clinicians must use their own clinical reasoning / judgement before applying this in a real world setting. Client perspective Anything the patient reports to you Ask the patient if they feel that they have any problems with their memory if yes then what types of things do they forget / struggle with / what effect does this have on their daily life, has their family expressed any concerns with their memory etc. Session objective / purpose moca cognitive screening assessment. If the patient has completed multiple cognitive assessments before this session I would also cite the scores and dates of these assessments to link them / show progression.Ĥ If the full summary of the assessment is available including a breakdown of scores by category consider listing these also as a comparison. Kitchen assessment completed see entry for full assessment details. Previous sessions completed If I am doing an assessment like a cognitive screen I would cite my previous entries to link them in the patient assessment journey with OT. Role explained A concise explanation is key - tailored to the session objective. Consent Consent for the assessment to be completed Notes / chart reviewed Reviewing notes prior to the session is very important, consider stating that observations were stable for treatment if working in a medical setting where patient s medical status may fluctuate or be precarious.ģ Before completing a cognitive screen consider if the patient has an active infection and whether this is likely to slant / effect the results of the assessment. The format used builds on the general notes hand out found here. before delving into this area! This example uses the montreal cognitive assessment ( moca ) which is a free cognitive screening assessment combined with a functional assessment. ![]() Most organisations have specific policies / practices around whether or not OT s complete cognitive screening assessment so is best to check with your supervisor / senior etc. An example of writing up a cognitive screen and linking it to occupational performance: Often in physical settings OT s will be asked to assess cognition and make recommendations on a patient s safety to return home this is quite a thorny area for us historically! The way I see it is that our role is to assess Occupational Performance and to provide recommendations on how to meet our patient s needs.Ģ In this type of case it could be done through a combination of a cognitive screening assessment and a functional / occupational based assessment. 1 Disclaimer: the above material is purely for teaching purposes and clinicians must use their own clinical reasoning / judgement before applying this in a real world setting. ![]()
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