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Wisconsin OT Screening and Evaluations

Screening

An occupational therapist, alone or in collaboration with an occupational therapy assistant, when practicing either independently or as a member of a treatment team, shall identify individuals who present deficits or declines in performance of their occupations including occupational performance skills and performance patterns.

Screening methods shall take into consideration the occupational performance contexts relevant to the individual.

Screening methods may include interviews, observations, testing and records review to determine the need for further evaluation and intervention.

The occupational therapist or occupational therapy assistant shall transmit screening results and recommendations to all appropriate persons.

Evaluation

The occupational therapist directs the evaluation process. An occupational therapist alone or in collaboration with the occupational therapy assistant shall prepare an occupational therapy evaluation for each individual referred for occupational therapy services. The occupational therapist interprets the information gathered in the evaluation process.

The evaluation shall consider the individual’s medical, vocational, social, educational, family status, and personal and family goals, and shall include an assessment of how performance skills, and performance patterns and their contexts and environments influence the individual’s functional abilities and deficits in the performance of their occupations.

Evaluation methods may include observation, interviews, records review, and the use of structured or standardized evaluative tools or techniques.

When standardized evaluation tools are used, the tests shall have normative data for the individual’s characteristics. If normative data are not available, the results shall be expressed in a descriptive report. Collected evaluation data shall be analyzed and summarized to indicate the individual’s current status.

Evaluation results shall be documented in the individual’s record and shall indicate the specific evaluation tools and methods used.

Evaluation results shall be communicated to the referring health care professional, if any, and to the appropriate persons in the facility and community.

If the results of the evaluation indicate areas that require intervention by other health care professionals, the individual shall be appropriately referred or an appropriate consultation shall be requested.

Initial evaluation shall be completed and results documented within the time frames established by the applicable facility, community, regulatory, or funding body.

Citation

Wis. Admin. Code OT 4.03

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