How to be a better OT

How to do an OT hospital initial assessment

• Clare Batkin - Your OT Tutor • Season 1 • Episode 1

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Do you feel robotic asking the exact same questions during every hospital initial assessment? Discover how to adapt your clinical interviews for every patient while effectively planning their safe and timely discharge.

Episode Summary: In this episode of the How to Be a Better OT podcast, host Clare Batkin breaks down the absolute bread and butter of acute and rehab care: the hospital initial assessment. Drawing on a decade of experience, Clare walks you through the entire process, from essential pre-assessment file reviews to documenting your findings. Whether you are a student, a new grad, or transitioning into a hospital setting, this episode will help you gather the right information to get your patients home safely and efficiently.

 

Key Takeaways:

  • The Ultimate Goal: Learn why the overarching purpose of any hospital initial assessment always comes back to safe and timely discharge planning.
  • The Prep Work You Can't Skip: Why reviewing medical files and getting handovers from the multidisciplinary team (MDT) is crucial before you even step foot in the patient's room.
  • What to Ask (and What to Skip): A breakdown of the core interview components, including diagnosis, social history, home environment, and previous vs. current function.
  • Adapting Your Approach: How to tailor your questions depending on the patient's age, diagnosis, and unique discharge concerns.
  • Documentation Hacks: Why SOAP notes don't work for initial assessments, and how to use subheadings and "sticker templates" for faster, more consistent note-writing.

 

Links & Resources Mentioned:

  • Freebie: Download the Hospital Initial Assessment Form from section 5 of the Learning Library to help guide your clinical interviews
  • Freebie: Access the Documentation Examples in Section 6 of the free Learning Library: 
  • Deep Dive: Join the Connector Membership for full webinars on how to conduct and document an initial hospital assessment (including a simulated demo), functional mobility assessments, functional cognitive assessments, and assistive tech prescription.
  • Advanced Learning: Join the Alliance Membership for advanced clinical content and NDIS courses.

 

If you found this episode helpful, please subscribe, leave a review, and share it with a fellow OT. 

Make sure to tune in to our next episode, where we'll shift our focus to the private sector: How to do a Functional Capacity Assessment (FCA)! 


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And really the key piece of information that we need to take away from knowing what their previous function is and what their current function is, is what is the gap? So a person doesn't always need to be back at their baseline to be able to leave hospital, but the gap between the previous and current function is the starting point for what we'll recommend, whether it's equipment, support services, or some more time and practice on a rehab ward. Welcome to the How to Be a Better OT podcast. I'm Claire Batkin, an OT and clinical educator who is on a mission to make professional development simple, practical, and worth it for OTs. If you're ready to step back from the overwhelm and bring core frameworks to life, join me for step-by-step guides and practical solutions that will build your confidence and competence so you can deliver the best outcomes for your clients and truly love what you do. Hi, and welcome to the very first episode of How to Be a Better OT podcast. I'm really excited to be kicking off this brand-new 10-part series, where we're going to dive into my version of some practical how-to guides for some core OT clinical skills. Today, we're starting with the absolute bread and butter of hospital OT care, the hospital initial assessment. So basically, a hospital initial assessment is an interview-based assessment completed by OTs with inpatients in a hospital setting. Now, I spent a decade working as an OT across a range of hospital caseloads, from fast-paced acute wards to longer-term rehab settings, and I can tell you that getting this right is a skill that will make it so much easier for you to do your job well. You need to be able to do these initial assessments efficiently, but most importantly, you need to be able to adapt them to suit your client and your caseload. Now, if you're doing initial assessment well, you should never be acting like a robot and just asking the exact same questions in the exact same way every single time. So imagine this, the questions you ask 28-year-old Sammy, who's stacked it on her skateboard and is being discharged from an ortho ward with a fractured leg, is gonna be very different to the questions that you'd ask a 78-year-old Shirley, who is recovering from a severe chest infection and deconditioning. So we can use examples like this and go a little bit deeper as we start to work our way through the process. But what I'm hopefully gonna show you today is that the underlying process is exactly the same. Now, before we start, if you're listening to this but also a bit of a visual person who likes to have something to look at to keep track of the process as we work our way through it, there's a free hospital initial assessment form available in my learning library. So this was a resource that I developed many years ago and that many OT students and OTs have since used to help them remember what questions they need to cover in an initial interview when they're first learning. Now, as we go through this podcast series, I'll probably be pointing you back to the learning library for some other resources as well. But the good news is that you can sign up for free, and only have to remember one set of login details, and you'll be able to access any of the freebies that I mention in this podcast in one place. The link you need to be able to do this will be in the show notes. Okay, now first up, before we get into the nitty-gritty of all those different questions that we'll actually ask in an initial assessment, let's just rewind a little bit and talk about the why. So what is the main purpose that we're trying to achieve when we do a hospital initial assessment? So in a nutshell, the overarching goal of any OT intervention in a hospital setting is to get the person home from hospital or to contribute to that discharge planning. So we're trying to get them home or to some sort of new accommodation outside the hospital as quickly as possible. But because we're OTs, I'll also add that there's a massive caveat to that. We want them out as quickly as possible, but as safely as possible, and that really is our primary lens. So even if someone has had a significant stroke, and they're going to be in hospital for a long time, Ultimately, in our initial assessments, we're trying to find out what they need to be able to do safely to eventually go home. So the context around this is that time is really a luxury on a busy acute hospital ward. Even when we know that patient is destined for a long inpatient rehab stay, we still need to get a discharge plan in place ASAP so that the patient can move to the next part of their hospital journey. So we need to do our initial assessment at the right time and as efficiently as possible, as it often holds the key to what a realistic discharge could look like for our client. We also need to remember that hospital procedures rely on a collaborative multidisciplinary team. So the information that goes into our initial assessments and that we need to share afterwards needs to have that multidisciplinary lens in mind. But to do that well, it all starts with your prep work. Now, before you even step into the patient's room, you have to do some prep. So don't skip this step. Basically what I'm talking about by prep is a file review and probably a conversation with some other people on the ward as well. So first of all, the file review. Check the medical notes to find out why the person's in hospital in the first place, but also who has already seen them on the ward. Now, this can save you a lot of time and frustration for the client because you can confirm information rather than asking them the same questions that somebody has already asked them. It can also point you in the direction of what type of questions to ask in the first place, and also which questions you can leave out, and I will give you some case study examples as we go through this podcast. But firstly, which are the most important parts of a medical file to look at, especially if they've already been in the hospital for a while before you get the referral, and you don't have hours to read everything word for word? I would say start with the first doctor's entry, which will set the scene for why they came to hospital in the first place. But then also look over the entries from the past few days or just from that day if they've only just come in, as that will confirm what the medical plan is, and usually it will also have some details for when the patient is likely to go home, especially if that date is getting close. So this estimated discharge date, and sometimes you'll even see it on a ward whiteboard as an EDD, is really crucial to know because this is what the rest of the team will be aiming for to get the person home from hospital. As soon as a person is medically stable, we need to be speaking up if there's a good reason why that person is not ready to go home from a functional perspective, or the bed managers will be asking why they're still in hospital. Some other helpful notes to look at are the physio entries. So they'll often have details about some basic social history, such as who the person lives with, as well as what their baseline and current level of mobility is. Some other entries will also be more important at different times depending on the patient. So for example, a speech pathology entry could be really crucial to read for someone who's been admitted to hospital following a stroke, and the doctor's entry lists aphasia as one of the impairments. So we can't do an initial interview with somebody who has significant communication impairments, So we really want to have a look at the speechy entry and see what they're saying about the person's communication skills. Another one that will always be helpful to look at for all patients will be the nursing staff entries. If you scan back over the past few days, you'll be able to see what sort of assistance the patient has been receiving for their self-care. So are they walking themselves to the toilet? Do they need help with things like showering? It'll also have information about their basic cognition, such as if they're orientated and following instructions. Um, and these will form the deeper questions that OTs will then go on to ask about things like cognition and self-care when we're doing our initial assessment. Now, if there are no notes available, talk to the multidisciplinary team on the ward. So get a quick handover from the nurse looking after the patient, or grab the physio who just walked out of the room and find out what they can tell you about the patient. Now, if you're a shy OT student who would find this terrifying, communication skills is something that I teach frequently in my paid CPD memberships, and I'm sure I'll probably also do a podcast episode on how to do a good clinical handover in the future. But I'll drop some suggestions in the show notes if you want something else to help with that. So now, if you know all of this from the notes or from a quick chat, why they came in, how they're mobilizing and functioning on the ward, what their communication and cognition is like, along with their anticipated discharge date, you'll be able to better plan what questions you're going to ask in your initial assessment. It will tell you whether the session you do today is just going to be a quick introduction and five minutes worth of information gathering that you need to follow up on a different day, or whether you need to do a comprehensive hour-long initial assessment that also includes some discharge planning all in one go. So now you've done your prep, you walk in, you introduce the OT role, and you start the interview. What are we actually covering? Now, this is where you can refer to that hospital initial interview form that I mentioned at the start. At a minimum, you're going to want to make sure that you have information about their diagnosis and relevant medical history, their social history, home environment, previous function, current function, and also what their goals are and what their discharge concerns might be. And now I'm going to take you through each of these one by one. So firstly, in terms of diagnosis and past medical history, this may not actually need to be a question that you formally ask during your initial assessment. It may be something that you can actually gather from the initial file review that you do. So just keep that in mind that you don't always need to start every interview with this really formal and sometimes quite personal question. Um, you also want to make sure that you cover the social history. So this is things like who do they actually live with, and do they have any sort of services or help at home? So particularly for our older patients in hospital, it may be that they already do have some services through government-funded programs to help with things like shopping and cooking and cleaning. Or it could be that they're privately paying for this type of help as well, and that's really helpful for us to know because often we're looking at whether they need help with these sorts of activities upon discharge, who's going to be doing them. Then we ask about their home environment. Now, sometimes the information that we can get from initial interview alone is perfect for what we need. Sometimes we need to just use that as a starting point, and then we'll go further and do things like requesting photos or videos from family members or even needing to do some sort of home visit. Now, that is a whole other topic all on its own, and it is actually one that I do have planned for a future podcast episode. So keep listening if you want to find out how to do home assessments as well. So in terms of home environment, we want to know do they actually own their own home or do they rent it? Because this will influence any recommendations that we might make regarding things like home modifications. We ask what is the access like, so how do they actually get in and out of the house? Is there stairs? Is there a lift access? Are there any handrails in place? This could be really important if someone's coming out of hospital with some sort of physical impairment or change to their physical condition and maybe using a walking aid for the first time. We ask about their bathroom as well. So what is their shower like? Is there a shower recess? Is it a shower over a bathtub? We ask about their toilet. So is there anything fancy about it? Is there grab rails or is there any equipment in place? Is it in the same room as the shower? Because this will give us an indication of how much circulation space they're likely to have if they may be going home with that new mobility aid for the first time. Now, you can also ask them questions about things like what their lounge room is like, what their bedroom's like, but this is where it comes down to thinking about what is going to be most relevant for this person and their individual concerns for discharge. If we know that somebody's going to have help with all their cooking and washing their clothes upon discharge, we don't really need to go into the nitty-gritty of what their laundry looks like. Another example could be that if we've been referred to see somebody for an initial assessment and their issues are more around their cognition and education about return to work or driving following a mild head injury, we probably don't need to go into detail about what sort of furniture they have in their lounge room because we don't actually have any concerns about their chair transfers. And if we did actually start asking them questions like this, they're probably going to give us a bit of a funny look and they're going to be like, "Why do you even need to know that?" So even if there is space on your initial assessment form that reminds you to ask a particular question, always go back to your clinical reasoning in terms of is this information relevant to this person's discharge plan? If it's not, it's probably just wasting your time and the patient's time to be asking and recording that information. Now, having said all that, if you are an OT student or a new grad, the disclaimer is to always go back to your supervisor and ask about what their preference is. It may be that for practice sake that they do want you to ask all of these questions because it's better to have this information and not need it than to not have it while you're still developing your clinical reasoning and being able to make that judgment call about what's important or not important. But this is just an example of how if you're watching your supervisor do an initial interview and you're like,"They didn't ask this question that's on the form," it may be that they've already done this clinical reasoning process and worked out that it's actually not essential for this person, so they've decided to leave it out. It's the same thing when we come to asking about the person's previous function, in that sometimes there are questions that we don't need to ask or that we don't need to go into as much detail about, depending on that patient's individual circumstances. So if we go back to those examples that I mentioned at the start where we have the young person who's recovering from a leg fracture who's going to be going home non-weight bearing for a little bit of time, and we also have that older person who's deconditioned, we can ask questions about their previous function in slightly different ways, but still tick the box in terms of covering things like previous mobility status, self-care status, and how they were managing their domestic tasks. So for example, for the younger person, if you started to say, "Were you normally independent with your self-care, like having a shower by yourself?" Again, you're probably gonna get a bit of a strange look. Now again, the caveat to this is that this is for somebody who we know has no other significant medical history or background disability. If somebody does have a disability, then you're not going to be asking this question in that way. But for this young person who does have a fracture after riding a motorbike, no other previous medical history, who was previously working a manual job as a tradie, we can assume that most of the time they were probably independent with their self-care. So instead of saying, "Did you normally manage all your showering or toileting by yourself?" We could instead ask it in a different way, such as, "Now I'm assuming before this happened, you never had any other difficulties with getting around or managing your day-to-day activities, or is there something that we're missing?" Versus if we had our older person who's coming with a chest infection, and then from their notes, we can see that they've actually had some other previous admissions and some falls, we're going to be asking a lot more detail about that previous function. So one by one, we'll actually go through, "Before coming to hospital, how did you normally manage your walking? Did you need a walking stick or a walking frame? How do you normally do your showering? Do you sit on a shower chair or do you stand up? Or did you ever need help with things like cooking your meals? Who gives you help with that?" Now, it's not just about leaving questions out, but sometimes it's about remembering to ask the extra questions. So if normally on your orthopedic ward, you're working with people who are seventy-five years and older, it's probably not your normal routine thing to ask about their work status and what their work is. Whereas when you have the occasional younger person who comes through, this is something that is important to ask about in case they do have concerns about their ability to return to work or their finances. And this might mean that we need to refer them to a social worker who could help them with these things. So remember, we're still making sure we know what their status was in terms of their mobility, their self-care, and their domestic tasks, but the way that we ask the questions and the level of detail that we ask will vary depending on the person. Now, the more you do these assessments, the more you build your confidence in knowing what's important information and what's not so important, this will become a lot easier to do. Now, some extra questions that can be really important for some patients in some situations which may not routinely make it into every hospital assessment are things like managing finances. So if somebody has cognitive impairments and they're normally solely responsible for managing their own bills, This is something that we might want to flag with their family, with the doctors or the social workers. Likewise, sometimes doctors forget to ask about the important task of driving, or we may make the assumption that an older person with significant impairments couldn't possibly be driving, but often this is not the case. So even if it's not the OT's job in that hospital ward to provide the medical advice about fitness to drive, we are often the people who will be asking the question to find out if they are driving, and then we can use that information to open up further discussions about safety if it will be an issue for that person. Some other things that you'll find on that freebie hospital initial assessment form is that I often like to ask about their upper limb function, and again, this can be more important on something like a neuro ward where someone's likely to have some upper limb impairments as a result of a stroke or a head injury or some other progressive neuro condition. So you want to know what their baseline upper limb function was and also what their dominant hand was. You can also ask about cognition as well. So again, big one for neuro wards and for the aged care wards especially. Was there any baseline concerns about the person's memory, orientation, or decision-making ability? And lastly, sensory. So again, for the aged care wards, it can be really important to ask about things like their vision and their hearing and to not just assume that the person can hear us clearly or that they'll be able to see and find their way around the ward. It may be that it's really obvious from their medical file that they have some vision loss resulting from something like macular degeneration, but sometimes it's not obvious, and if we do ask those questions, though, it can be really helpful for our ongoing discussions and interventions that we're planning with that patient. Okay, so that was all the questions about their previous function. How do we gather the information about their current function? We can actually do this in a few different ways, and the method we choose will depend on things like how the patient is going with the interview. So are they getting tired, or are they still up to answering more questions? Also, what their functional status is on the ward based on the information we read in that file review. And what I mean by this is if somebody's barely able to participate in an interview and it's actually their family member providing some information, that family member may not be able to tell us a lot about how the person is mobilizing or managing their self-care on the ward unless they happen to be there to see it. So instead, we can get that information from the notes or from a conversation with the nurse or the physio. Now, if the person is able to give us some information, then it is worth asking how are they managing on the ward. And you can ask things like, "Have you been up with the physios yet? How did you go? Have you had a shower this morning, and did you need any help from the nurses with that?" And also, "How did you feel doing those tasks? Was it difficult, or was it easier than expected? Or has it made you worried about anything for going home?" And in a minute, I will go into a little bit more detail about how to ask more about the patient's perspective on their discharge plans. Sometimes if we have time, the patient's up to it, and we think they're likely to go home in a couple of days or less, we can actually get them up to show us some of those things, like how are they transferring off their bed, chair or toilet. In this case, it goes beyond an initial assessment interview only to also include a functional mobility assessment, and I'll also come back to that in a moment too. Finally, most of the time when we're doing an initial assessment, we don't actually assess their current function with domestic tasks, or they won't have had an opportunity to practice things like meal prep or laundry unless they are on a rehab ward. So you'll see on my hospital initial assessment template the heading in that section is discharge plan. So instead we're asking how are they planning to do those domestic tasks when they do go home. And really the key piece of information that we need to take away from knowing what their previous function is and what their current function is, is what is the gap? So a person doesn't always need to be back at their baseline to be able to leave hospital, but the gap between the previous and current function is the starting point for what we'll recommend, whether it's equipment, support services, or some more time and practice on a rehab ward. And then the final piece of the puzzle goes back to our client-centered OT practice and collaborative decision-making. So while we may be asking all these questions and forming our own opinion and planning in our head about what the likely issues are for discharge, what that person's concerns might be and what sort of help they may want, we can't make this assumption. We need to actually make sure that we have space in this initial interview to actually explicitly ask the client, or if they're not able to express their wishes themselves, ask their family about these things. So we want to know what are their concerns for discharge? Is there something in particular that they're worried about managing? And we should also be asking about what their goals are for discharge. So are they wanting to be fully independent with all their self-care before they go home? Or are they quite happy for their family members to provide that initial help while they're recovering if it means that they can get out of hospital a few days sooner? Sometimes we can make the assumption that they need to be fully independent with their self-care because they normally live alone. But maybe in the background, their family member has already said, "Nope, I'm moving in for a short period of time to be able to give you that help," because they know that their loved one wants to get out of hospital as soon as possible. But we don't know this information unless we explicitly ask it. So ask about their concerns for discharge, their goals for discharge, but also whether the person or their family members are already making plans behind the scenes that will relate to this person's discharge from hospital. Okay, so now you've gathered all this fantastic information. Sometimes, and a lot of the time, it's that this initial assessment finishes here, and then you can go and do your documentation, which I will cover in a minute. But as I mentioned earlier on, I just wanted to let you know that sometimes when we have to move really quickly, maybe we need to do our initial assessment on the same day that the person needs to be discharged from hospital, which is actually quite common in an acute medical ward, we need to extend this initial assessment to then turn it into an intervention session as well. So if during our initial assessment we identified that somebody's likely to need some equipment or assistive technology for discharge, such as a shower chair or a toilet frame, we then need to go a little bit further with our assessment. So we'd actually go and do a functional mobility assessment and get them to show us how they get on and off their chair, in and out of their bed or on and off their toilet, and then we can go and organise that equipment. So whether it's coming from a hospital loan pool or whether we're just providing them with a list of private suppliers in the local area, and then obviously all the education that goes with that as well. Now, those are some big topics all on their own, so I will cover those in some future podcast episodes if that's of interest to you. But just to let you know, sometimes your initial assessments and the documentation that it includes will involve more than just what we're going to be talking about in our next example of documentation, which is just that initial assessment where the plan's going to be that you come back and do all of those intervention things at a later stage on a different day. So now let's dive deeper into documentation. Now let me start by saying that it's my personal opinion that SOAP style notes do not work for an OT initial assessment, and that using a different form of template of subheadings is going to be much more effective for you. Now, you're still going to include subjective and objective information, but the flow when you go to write it out is going to make a lot more sense to you if you use that freebie initial assessment information form and the subheadings on that as your subheadings when you're documenting. Now, how you document will also depend heavily on the hospital you work in. So if your hospital uses electronic medical records, there will likely be some templates available for you to use for your initial assessment. If you're still handwriting in paper medical files, I highly recommend using some set subheadings for consistency. And here's a great tip. If you're doing really repetitive quick screenings, such as on a busy ortho or neuro ward, where you don't really need that full lengthy detail, see if you can use some printed note stickers that act as like a mini template to put straight into your paper notes. Now, I developed a sticker template for doing quick screening initial assessments for people who had been admitted with a TIA to a neuro ward with no residual symptoms, and it really worked a treat for not only saving time in the documentation process, but also making sure that there was some more consistency between staff so that we were asking the same types of screening questions and all recording the same type of information, which was directly informed by the clinical practice guidelines related to stroke. Now, if you'd actually like to see an example of what a documented hospital initial assessment could look like, there is another freebie that does show you exactly this, and it's in the learning library. So again, sign up to that, scroll to section six, and that's where you'll be able to see some documentation examples, including an initial assessment example. But if you do want a little bit of extra help to fully unpack the documentation side of things, if you go to my paid memberships, in particular the Connector membership, we do a whole one-hour webinar just on how to document a hospital initial assessment. So that might be worth checking out if it is something that you're struggling with. So now we've done our initial assessment and we have some great information that's going to inform our discharge plan, and we've documented it all, so it's been made really clearly available for the rest of the team to see as well. But do make sure that you pick out any of that important information that particular team members may be interested in and give that handover verbally as well, particularly if time is crucial and it's unlikely that the person will be able to read your notes straight away. But then what comes next? So next we need to decide what our OT plan is going to be, including what's left on our to-do list for this patient and when are we going to do these further assessments or interventions. Now, at the end of your documentation, the last part of it, make sure that you clearly state these two things. One, is the person safe for discharge? If they're not because you need to do further assessments or you need to organize some equipment, or they're just way below a level of function that would be safe for them to manage at home, then clearly use the words"patient not safe for discharge." But then you need to give the people reading, particularly the doctors and the nursing unit manager, a little bit more information about what will make them safe and what your involvement is going to be in getting them there. So number two is make sure you also include a plan which outlines what you'll be doing next and when you're going to be coming back to do it. So this could be things like ongoing functional mobility assessments, it could be prescribing equipment for discharge, or maybe you need to speak with some family members to confirm some collateral information before you can confirm that somebody is safe to go home. Just be clear about what it is that you're doing and the time frames involved, and it will really help that multidisciplinary collaborative approach to getting this person home as soon as possible and as safely as possible. Okay, well that brings us to the end of a jam-packed first episode of the How to Be a Better OT podcast. If you found this information helpful, but you want to do a deeper dive, I'll let you know what else is available. So within my Connector membership, there's a whole webinar where I give a mock demonstration of how to do an initial assessment, so you can actually see how I ask the questions to gather that right information. As I mentioned before, there's also a separate one-hour webinar on how to document an OT initial assessment, and the Connector membership also has a bank of over 50 tutorials on lots of other core OT skills, which will be particularly helpful if you're an OT student going out on placement or even an experienced OT who's working with adults with physical conditions for the first time, either in a hospital or community setting. So we cover topics such as functional mobility assessments, self-care assessments, functional cognitive assessments, standardised cognitive assessments, equipment prescription, and much more. So in the show notes, you'll be able to see a link where you can go and find out more about that membership. Now, if you're an experienced OT, the Connector content is also built into the Alliance membership too, which is the next level up, and that just gives you a little bit more content at a slightly higher difficulty level. And if you're an Australian OT, it also includes some of my NDIS-focused courses. So thanks for sticking around to the end. I hope you found it helpful. In episode two of this series, we're going to flip the script and go from public hospital to private community settings, and we're going to be talking about how to do a functional capacity assessment, which is the bread and butter equivalent for occupational therapists working within the NDIS in Australia. I'll see you then. The information shared on this podcast is for general educational use only, so please always use your own clinical reasoning and seek appropriate professional supervision for any individual client situations. If you'd like to learn more with Your OT Tutor so that you can be a better OT who loves what you do, check out the Your OT Tutor website. The links will be in the show notes. There are free resources in the learning library, paid CPD memberships, online courses, supervision and mentoring opportunities, and options for your team to all learn together with me.