Assessment Protocol

Shane Brooks

RECTH 3360 Assessment Protocol

Prof. Karen Wenzel

April 11, 2021

 Assessment Protocol
The Phoenix Recovery and Counseling Centers
 Preparation
o Protocol Review
 Before any patient (pt)assessment, the Recreational Therapist (RT) will
sit down with their supervisor to go over the assessment protocol. They
will determine if it will be a mental health, substance abuse assessment,
or comorbid assessment at that time.
o Record Review
 The RT will review the pt record for basic intake information. RT will
be gathering the data before setting up an in-person interview.
 Medical History
 Diagnosis
 Medications
 Pt and family history
 Social and Behavioral concerns
 Any known barriers to treatment
o Environment
 When the RT has scheduled the interview, they will set it up to be in
either the facilities interview room or the pt room. The goal is to keep
the pt calm and relaxed. RT should remember and consider the
following.
 Privacy
 Comfortability
 Limit Distractions
o Interview
 When conducting the interview, the RT needs to keep the interview
between 30-60 minutes.
 Must be completed within the first 72 hours of admission to The
Phoenix
 Follow the guidance of the suggested interview questions (attached)
 RT will be prepared with the following for the interview
 Company Ipad or laptop for notes
 (3) Pens: (1) for the RT, (1) for the pt (1) backup
 A clipboard and notepad to take notes
 Notepad for the pt if they do not want to speak their answers.
  Assessments CERT Psych R Section I& II, K10, & Duke Health
Profile (attached)
o Standardized Assessment Instrument(s)
 RT will review which assessments they need with their superior and go
over each form's instructions to make sure they know how to implement
them properly.
 Assessment Tools are
 CERT Pscyh/R
 K10
 PHQ9
 PCL-5
 DUKE HEALTH PROFILE
 S2BI
 Assessment Administration
o Protocol Review
 RT will review diagnostic, interview, and assessment protocols before
administering them with their supervisor. By doing so, The Phoenix can
ensure that each pt is receiving the same assessment leading to more
accurate placement into their RT programs.
o Record Review
 The record review allows the RT to cut down on some of the interview
questions. By doing this, it can also make the pt more comfortable and
help build a rapport. Sometimes the pt is tired of repeating the same
answers, so the less time the RT spends on information found elsewhere,
the better.
o Interview
 The interview is an essential and crucial aspect of the RT process. It is
the first chance to develop rapport and a therapeutic relationship with the
pt. When the RT is conducting the interview, it should have the
following aspects:
 Natural flow to the conversation
 Not be rushed
 Only be guided by the RT, really lead by the pt.
 RT will make sure to ask open-ended questions to elicit the best
responses from the pt. RT will follow the suggested interview questions
(attached). Questions are only a guideline, not a requirement. They are
open for deviation as pt information allows.
 RT will provide an introduction that will include but is not limited to the
following.
 Name, Position, and role.
 What recreational therapy is and going to do for their treatment.
 A version of the mission statement
 Let them know that they need to answer to the best of their abilities
and do not have to answer if they do not want to.
 Pt Interview
 It will be conducted face to face. Verbally if possible but can be
done with written answers if pt prefers.
 The interview can be ended and continued if the patient is
experiencing fatigue, hallucinations, or severe withdrawal signs. In
this case, it will be reattempted within 24-48 hours of ending the
interview.
o Observation
 The RT will have a group of several patients in a group and be observing
no more than five at a time.
 Groups will be focused on common goals for the facility and not
treatment-specific goals.
 Group will be conducted within 24-72 hours of pt interview.
 Group will be led by an RT and be an RT-focused group. May have (2)
RT’s in the group to be observing more pt’s
 RT will be looking at the following
 Attendance
 On-Time
 Late or left early
 Absent without reason
 No Show
 Appearance/Hygiene
 Appropriate
 Disarranged Clothing
 Suggestive dress, or wrinkled and soiled clothing
 Very meticulous, or very wrinkled and soiled clothing
 Very wrinkled and soiled, poor hygiene
 Coordination
 Well-coordinated gait
 Shuffling gait
 Stiff, awkward gait
 Spastic draws attention
 Unable to walk
 Items in CERT-Psych/R section III
 Group Performance
 Group Interaction
 Handling of Conflict in the Group
i. When not directly involved
ii. When directly involved
  If the RT has any questions about what they are looking for, the
supervisor will answer them during the protocol review.
o Standardized Instrument(s)
 CERT-Psych/R is used to help evaluate the pt behaviors that relate to
successfully integrating into society.
 K10 is used to help assess the pt depression or anxiety levels
 PHQ-9 is used to help assess the suicide risk of the pt.
 PCL-5 helps the RT learn what might be triggers for the pt with Post
Traumatic Stress Disorder.
 Duke Health Profile is used to help get a basic physical assessment of
the pt.
 The S2BI is used to know the pt's current substance use patterns so the
RT knows what medical issues may arise during activities.
 Scoring
o Scoring will be calculated with each attached scoring sheet to the corresponding
assessment.
o Scores will be recorded within 24 hours of the assessment.
 Analysis and Interpretation
o Record review
 The following will be looked at
 Name
 Age
 Date of Admission
 Primary Diagnosis
 Comorbidities
 All potentially related information for the criteria to the diagnostic
protocol
o Interview & Observation
 The RT should look at the following and report on the current pt status
in each.
 Social
 Ability to communicate clearly
 Social support
 Family Support
 Ability to set boundaries
 Physical
 Physical fitness
 Past, current, and future goals and interests
 Emotional
 Ability to express appropriate emotions
 Ability to communicate emotions
 Ability to adapt coping skills from past coping skills
  Understanding the mind and how it works regarding
emotions
 Cognitive
 Ability to problem-solve.
 Ability to control cravings or mental health setbacks.
 Interested in goal setting and achieving them.
 Spiritual
 They understand their spiritual needs.
 Pt is working to live within that picture.
 Recreational
 Past, current, and future recreational interests.
 Willingness to try new things.
 Understanding what recreation is.
 Limitations
 Pt understands their limitations.
 Pt is working towards improving them.
 Ability to admit their shortcomings.
 Strengths
 Past, current, and future strengths.
 Ways to improve and add new strengths.
 Expectations
 Expectations during treatment.
 Expectations outside of treatment.
 Reporting
o RT will chart in the pt medical record within 24 hours of any interview,
observation, or assessment.
 Copies of pt answers and scoring sheets will be uploaded to their record.
 The note will be written in a narrative format.
 Reassessment
o RT will reassess the pt twice during their treatment. Once in the middle of their
program and once before discharge.
 References
Boston Children's Hospital (Ed.). (2014). Screening to Brief Intervention (S2BI) Tool.

http://www.mcpap.com/pdf/S2BI_postcard.pdf.

Burlingame, J. (2010). Comprehensive Evaluation in Recreational Therapy- Psych/Behavioral, Revised.

In T. M. Blaschko (Ed.), Assessment Tools for Recreational Therapy and Related Fields (4th ed.,

pp. 328–336). essay, Idyll Arbor, Inc.

Duke University Medical Center (Ed.). (2017). DUKE HEALTH PROFILE (The DUKE).

https://fmch.duke.edu/sites/fmch.duke.edu/files/cfm/Research/HealthMeasures/DUKE%20Combi

ned%20Form_revised%20Jan%202017.pdf.

Kessler, R. (2002). Kessler Psychological Distress Scale (K10). https://www.tac.vic.gov.au/files-to-

move/media/upload/k10_english.pdf.

Spitzer, R. L., Williams, J. B. W., & Kroenke, K. (n.d.). PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-

9). https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf.

Weathers, F. W., Litz, B. T., Palmieri, T. M., Marx, B. P., & Schunnr, P. P. (2013). The PTSD Checklist

for DSM-5. https://www.ptsd.va.gov/professional/assessment/documents/PCL-

5_LEC_criterionA.pdf.

Attachments

Attachment 1:

Interview Questions

Therapist Introduction
Hi there, my name is_________, and I am a Recreational Therapist here at The Phoenix.
I am here to help assist you through your recovery and healing. My goal is not only to help
empower you to a place that you can celebrate life and have lasting solutions but also to help
you live an independent and freely chosen leisure lifestyle. In order to assist you in that
growth, I am going to have to do a few assessments. These will gather some information about
you that I could not get from the team meetings and your record. I will keep these to a
minimum. However, this information is vital to help make your time here at The Phoenix
enjoyable and have you a part of your recovery path.

Client Introduction:

 Can you tell me about how you spend time with your family? If not, what are the
reasons?
 When was the last time that you were having fun and where were you?
 If you could change something about your past, what would you change?
 What are some of the treatment options you tried before? If so, how did they work out?

Activity to Guide Interview:

Not appropriate for this assignment.

Interview Questions

An idea of how you can ask a series of questions:

I am going to ask you a few sentence stems, and I would like you to complete the questions:

 When you think of leisure, what do you think of?

 Your biggest struggle when it comes to Leisure activities is?
 Your view of yourself is?
 What do you want out of your time here at The Phoenix?
 What are some of your current leisure activities?
 What will give you confidence in yourself to choose a leisure lifestyle freely?
 Are there any activities you would like to try? Or not try?

Social:
 What is your current mood?
 If I let you pick an activity for us to do right now, what would it be and why?
 How many people are present when you do an activity usually?
 What is your family like?
 How do you see yourself in your social group?
 How many of your friends/family are still using or engaging in destructive behaviors?
 What would be your ideal world for you specifically?
Physical:

 What is something you want to improve about yourself physically?

 What were you like before your addiction/symptoms began, if you can remember?
 Could you tell me what you would say is the most concerning part of your physical
health?
 When it comes to leisure, what is your understanding of how physically fit you have to
be?
 How does your physical health affect your mood?
 Can you tell me how you physically see yourself?
 How does your vision of your physical self influence your leisure activities?

Emotional:

 How often does your mood change?

 Tell me about your mood over the last month?
 When was the last time that you were in a good or joyful mood?
 When you are depressed, what are some things you do to help yourself get out of that?
 How difficult do your emotions make it for you to partake in any leisure activities?
 What do you think will help to stabilize your emotions?

Cognitive:

 If you were in a situation where drugs were being used now that you have committed to
being sober, what would you do?
 When you see a friend struggling with something emotionally, how do you handle that?
 Can you tell me about a time in which you navigated an awkward situation?
 If you paid your rent and your landlord comes and says you did not pay it, what is your
reaction?
 To stay committed to a healthy lifestyle of chosen leisure, what are some things you
need to put in place?

Spiritual:

 What are your spiritual beliefs?

 How important is it to you that those are worked into the recovery program here at The
Phoenix?
 If someone has a different spiritual belief than you, how do you handle that?
 Can you tell me about some of the leisure activities that your spirituality supports?
 What is a scenario in which your spirituality does not support your recovery?

Recreation:

 When it comes to recreation, what is your understanding of it?

  Can you tell me your favorite recreational activities?
 Are there any recreational activities that you do not enjoy?
 How often were you engaging in recreational/leisure activities before coming to The
Phoenix?
 What are some things you want to improve on in terms of your recreational interests?
 If you were given a free choice to do a recreational activity right now, what would you
do?

Limitations/Barriers to leisure:

 When it comes to leisure, what is stopping you from doing more?

 What holds you back from thoroughly enjoying the activities you do enjoy participating
in?
 What prevents you from experience relaxation during leisure activities?
 Can you think of any limitations that would stop you from participating in leisure that
we have not talked about?

Strengths/Recreation abilities:

 What would you say are some of your strengths?

 What was the reason you came into The Phoenix to help with your substance use/mental
health?
 When it comes to recreation, what do you currently feel that you are capable of doing?
 How often do you push yourself beyond your recreational limits to see what you are
capable of?

Patient Expectations:

 How do you want me to assist you in your recovery?

 Can you explain what you want from the staff here at The Phoenix?
 If you do not want to participate in the programs, how do you want the staff to engage
and encourage you to participate?

Conclusion:
Thank you for letting me take some time out of your day to ask these questions. I know
it can be repetitive in the beginning having myself and other members of the treatment team
ask you questions. I want you to know that this was important and helpful. I will use this
information to get you into groups and activities that will set you up for success to empower
you to celebrate life and have lasting solutions. What is going to happen now is a few more
assessments to narrow down some specific items. The program will then address your
limitations and barriers first before we advance to handle some education about leisure and
recreation. Thank you again for your time today, and this concludes our interview. I will see you
soon.
Attachment 2:
http://www.mcpap.com/pdf/S2BI_postcard.pdf.

Attachment 3:

https://fmch.duke.edu/sites/fmch.duke.edu/files/cfm/Research/HealthMeasures/DUKE%20Combined%20

Form_revised%20Jan%202017.pdf.

Attachment 4:

https://www.tac.vic.gov.au/files-to-move/media/upload/k10_english.pdf.

Attachment 5:

https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf.

Attachment 6:

https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf.