Assessment Protocol

Caitlyn Belcher
RECTH 3360
April 8, 2021
 Assessment Protocol
Warriors Heart

PREPARATION
● Protocol Review
○ Review current protocol at Warriors Heart facility
● Record Review
○ Review client’s records
■ Diagnostic review
■ Family history
■ Intake interview review
● Interview
○ Complete an in-person interview within the first 48 hours of admission to
Warriors Heart
○ Interview should be conducted in a quiet and comfortable environment for the
client
■ Interview lasts between 20 and 60 minutes
■ Comfortable temperature (68-72 degrees F)
■ Private area
■ Minimal distractions
■ Interview can be conducted outside, weather permitting
○ Review interview questions
■ See attached document for questions
○ Materials required for interview
■ Pens (2)
■ Clipboards (2)
■ Notepad (RT use)
■ Printed interview questions (RT use)
■ Copy of DASS assessment printed out (for pt use)
● Observation
○ Review observation of behavior listed under Assessment Administration
● Standardized Assessment Instrument
○ Make sure all papers for DASS assessment are ready before interview begins

ASSESSMENT ADMINISTRATION
● Interview
○ Introduction of self and facility
■ Name, role at Warriors Heart
■ Define recreational therapy and the role of the RT in client’s treatment
 ■ Encourage the patient to take their time on the assessment and interview
and that there are no right or wrong answers
○ Client Interview
■ Verbal face-to-face interview
● Ask all interview questions
● Allow pt to add additional information if they would like
■ Exceptional conditions
● If pt can not complete interview or refuses to finish, interview may
end and be completed within 24-48 hours
● Observation
○ Assessment of client behavior during the interview can be made with RT taking
note of the following:
■ Appearance
● Cleanliness of clothing, appearance of good personal hygiene
■ Body language
● Good posture or slouched/rounded shoulders, crossed arms and
legs, intentionally not facing RT straight on
■ Comprehension
● Does pt ask clarifying questions if they do not understand, are they
competing the assessment correctly
■ Attention Span
● Frequently distracted, is pt on or off task throughout the interview
● Easily startled
■ Eye contact
● good/appropriate eye contact, does pt look away often or avoid all
eye contact
● Standardized Instruments
○ Client is to complete DASS standardized assessment
○ Explain directions to completing assessment and make sure pt understands and
has ample time to complete the assessment
■ Depression Anxiety and Stress Scale

SCORING
● Calculate and record the scores from DASS assessment scoring instructions

ANALYSIS AND INTERPRETATION

● Record Review
○ Take note of:
■ Age
 ■ Gender
■ Admission date
■ Diagnosis
● Interview Observation
○ Provide details for the following information about the client. This is
representative of how the client is currently functioning in the following areas:
■ Social and Interpersonal skills:
● Client’s support system
○ Family
○ Friends
● Activities client engages with
○ Family
○ Friends
○ Coworkers
● Client’s ability to:
○ Set boundaries
○ Be assertive
○ Trust others
■ Physical Functioning
● Sleeping patterns
● Eating habits
● Physical health routines
● Physical strengths/interests
■ Emotional Functioning and Coping
● Previous and current coping strategies
○ Substance and/or activity
● Stressors or triggers for client
● Ability or regulate or control impulses
■ Leisure Functioning
● Past or current interests
● Does client use leisure as coping strategy (yes or no)
● Is client confidant in leisure abilities
■ Client Expectations
● What does the client expect to gain from treatment
■ Further Considerations
● Note any red flags for continuing treatment
● Past or current injuries
● Allergies
● Standardized Observation
○ DASS Assessment
 ■ The DASS is a set of three self-report scales designed to measure the
negative emotional states of depression, anxiety and stress
● Depression Scale:
○ Assesses dysphoria, hopelessness, devaluation of life, self-
deprecation, lack of interest/involvement, anhedonia, and
inertia
○ High score in this scale can be characterized by self-
disparaging, dispirited, gloomy, blue, convinced that life
has no meaning or value, pessimistic about the future,
unable to experience enjoyment or satisfaction, unable to
become interested or involved, slow, lacking in initiative
● Anxiety Scale:
○ assesses autonomic arousal, skeletal muscle effects,
situational anxiety, and subjective experience of anxious
affect
○ High score in this scale can be characterized by
apprehensive, panicky, trembly, shaky, aware of dryness of
the mouth, breathing difficulties, pounding of the heart,
sweating of the palms, worried about performance and
possible loss of control
● Stress Scale:
○ assesses difficulty relaxing, nervous arousal, and being
easily upset/agitated, irritable/over-reactive and impatient
○ High score in this scale can be characterized by over-
aroused, tense, unable to relax, touchy, easily upset,
irritable, easily startled, nervy, jumpy, fidgety, intolerant of
interruption or delay

REPORTING
● Assessment summary is completed and placed in client medical record
○ Scan assessment tools into medical record
○ Scan any additional notes into client medical record

REASSESSMENT
● Reassessment may be necessary after 14 days and prior to discharge
● Assesses goal completion and program effectiveness

REFERENCES
 Akin, A., & Çetın, B. (2007). The Depression Anxiety and Stress Scale (DASS): The
study of Validity and Reliability. Educational Sciences: Theory & Practice, 7(1).

Stumbo, N. J., & Peterson, C. A. (2010). Therapeutic recreation program design:

principles and procedures. Pearson Benjamin Cummings.

Therapist Introduction
Hello, my name is Caitlyn and I am a recreational therapist here. The purpose of today’s
interview is so that I can get to know you a little bit better and learn how we can better serve you
here at Warrior Hearts. I will be asking you some questions about your everyday life and some
of the things you like to do in your leisure time, and you can answer to whatever degree you feel
the most comfortable with. I will also be jotting down some notes if that is okay to make sure I
do not forget any important points. These questions are about you, so there are no wrong
answers, and your answers will not be shared with any other residents or staff.

Client Introduction
● Where did you grow up? Where do you live now?
● Can you tell me about your normal daily routine right now?
● Do you live with anyone else?
● What are some things that you like to do in your free time?

Interview Questions
Social
● Do you often make time to spend with other people?
● How would you introduce yourself to someone you have never met?
● Describe how you normally feel after spending an hour with a group of people.
● What usually stops you from reaching out to a friend?
● Is it easy for you to meet new people? Why or why not?
● What scares you the most about meeting someone new?
● Describe to me the most influential or important relationship in your life right now.
Physical
● If you walked into a rec center or community gym, what activities would you do?
● How does physical activity make you feel afterwards?
● How much sleep do you get each night?
● How do you view your own physical abilities?
● Would you say you succeed at most physical activities you try?
● Describe to me the feeling you get after getting your heart pumping during an activity.
● Do you ever experience negative thoughts after or during physical activity?
● If so, how do you deal with these thoughts?

Emotional
● What actions do you take to monitor stress on a daily basis?
● How would you say anxiety relates to your occupation/everyday life?
● How do your relationships affect your emotions?
● What kind of activities improve your happiness or enjoyment?
 ● When you feel happy and/or satisfied, what kinds of things do you want to do?
● When you are upset, what do you do to control your emotions?
● Describe a time when you had an emotional response that came out of nowhere.
Cognitive
● Given that two different activities take equal amounts of time and money, how would you
decide which activity to participate in?
● How would you describe your ability to problem solve?
● How would you describe the feeling of mastering a new skill?
Spiritual
● How important to you are your morals?
● Would you describe yourself as religious?
● If so, how does this affect your everyday life and the decisions you make?
● How do you feel like others view you as a person?
● How does recreation help you feel a sense of purpose?
● Do you feel more in control when doing a recreational activity?
● Describe how recreation activities contribute to your sense of self.
Recreation
● Tell me about some of your favorite activities to do outside
● What kinds of activities do you feel like you are good at?
● How often would you like to participate in recreational activities?
● How do competitive activities make you feel?
● Do you enjoy activities that include an adventure or risk aspect? Why or why not?
Limitations/Barriers to Leisure
● What equipment or items do you have in your room/home that are available for leisure
activities?
● What kind of things prevent you from fully enjoying your leisure time?
● Is there something that you wish you had more of in order to have a more enjoyable
recreation/leisure experience?
● How does money relate to your recreational preferences?
● Do you wish you had more knowledge of possible recreational or leisure activities
available to you?
● What activities would you like to learn more about?
● Is it easy for you to start new activities?
Strengths/Recreation Abilities
● Do you feel like you can succeed at most activities that you try?
● Describe your involvement with activities that challenge you mentally.
● Explain what your role might be in a new team activity.
● Do you think you work best alone or in a team?
● Explain how your skills might help others around you to also succeed.
Patient Expectations
● What do you hope to gain from being at Warriors Heart?
● Describe how you hope your life might change after your time here
● How can we assist you in reaching your goals?
Conclusion
Thank you for cooperating and answering these questions for me. That is all of the questions I
have for you; do you have any questions before we finish our meeting? This really helped me get
to know you better and learn how Warriors Heart can better serve you; we are finished with the
interview now. Thank you again for your time.