Assessment can be defined as “a systematic process of gathering and synthesizing information about the client and his or her environment using a variety of methods, including interviews, observation, standardized tests, and input from other disciplines and significant others, in order to devise an individualized treatment or service plan” (Stavola Daly & Kunstler, 2006, p. 188). This information forms the foundation of the individual TR plan and provides a baseline of the client’s functioning and status prior to intervention, which can be used to measure progress toward the desired outcomes.
There are guidelines and regulations that require assessments to be done in a specific period of time and to cover particular topics, which vary from agency to agency, depending on the oversight authority. In long-term care, an initial assessment must be conducted within 14 days of admission. In a psychiatric unit, the assessment must be completed within 48 hours of admission. This information should be part of every TRS’s orientation and included in the policy and procedure manual of the TR department. The TRS will obtain the specific regulations that affect TR services from her agency administrator or department head.
Regardless of the setting or specific components of the assessment, TR assessment should adhere to the following guidelines, which reflect person-centeredness, inclusion, and self-determination (Bullock & Mahon, 2000):
- Seek as much input as possible from the individual.
- Assess strengths, abilities, and desires as well as deficits and needs.
- Assess the physical and human environment as well as the individual’s skills and needs.
- Remain focused upon the individual’s goals and how he would like them to function in his life.
To conduct a meaningful assessment, the TR department should develop an assessment protocol, which indicates the type of assessment methods to be used, such as standardized tests, questionnaires, and interview questions; areas for observation and general guidelines for carrying out the assessment procedures; and the assessment toolkit. The assessment protocol should reflect the mission and purposes of the agency and the TR practice model followed by the department. In selecting the assessment procedures, the TR staff must consider the amount of time needed to administer them and determine if a procedure is realistic and reasonable in the context of the work setting. The TRS should not collect information that duplicates what is readily available in the client’s record or from other disciplines. It is essential that the TRS have the skills to conduct the assessment, which fall within the scope of TR practice. Assessments are conducted on clients at times of change in their life, whether due to illness, injury, loss, trauma, or relocation. Recognizing what the client is experiencing emotionally reflects the ethic of care. The TRS is obligated to use his skill to put the client at ease and foster an environment that encourages the client to engage in the assessment process. The client may benefit from participating in the assessment insofar as she has a chance to express herself and discuss topics of importance that have not been addressed in other interviews. The client has the right to refuse to answer any questions or to participate in any form of testing.
In order to conduct the assessment, the TRS reviews the sources of assessment information. These include the client herself, her family and significant others, the TRS’s observations, observations and input from members of the team, results of standardized tests, and the client’s record. The TRS may be required, in accordance with agency policy, to contact the client’s family by phone or letter, introducing herself and asking if there is any information they would like to provide regarding the client and his needs, interests, and strengths. The client’s record includes demographic information that is valuable in planning the TR program. Factors such as medical and social history, level of education, employment history, family structure, religious observances, voting practices, and area of residence may influence a client’s participation in TR. If this information is in the client’s record, it is not necessary to ask about it again unless clarification or amplification is needed. In the initial meeting with the client to conduct the assessment, the TRS can utilize more than one method.
The TRS can also bring along an assessment toolkit. The assessment toolkit contains simple, everyday objects that the TRS can use during the assessment interview to determine a client’s level of ability in different skill areas. While many skills can be assessed by the TRS through conversation and observation, she may find it helpful to use the toolkit to more actively and purposefully engage the client. The TRS asks the client to interact with the objects as necessary to obtain accurate and useful assessment information. The TRS’s manner should be respectful, and it is important to put the client at ease. The TRS may want to explain that the purpose of interacting with the objects is to help in determining the client’s level of ability and need for assistance or support during TR programs and in setting meaningful goals. Using the full combination of assessment methods helps to provide a comprehensive portrait of who the client is.