Occupational Therapy Self Assessment

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1 Occupational Therapy Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date Work Settings General acute care Adult/adult ICU Pediatrics/PICU Children s hospital Hand therapy Home health care Outpatient neuro Outpatient ortho Psychiatric hospital Rehabilitation hospital/inpatient rehabilitation unit Skilled care facility School setting Early intervention Subacute Orthopedics Hand injury Total joint replacement/upper extremities Lower back/spinal surgeries Arthritis programs Soft tissue injuries Knee injuries & total knee replacement Hip fractures & total hip replacement Mobilization techniques Prosthetics/amputations Cross Country Healthcare, Inc. Rev. 03/13 F0067 Occupational Therapy 1 of 5

2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Neurologic Alzheimers/dementia Degenerative diseases of the CNS Multiple sclerosis Parkinson s disease Spinal cord injury Adaptive equipment Neurodevelopmental testing (NDT) Wheelchair evaluation Stroke acute Stroke rehabilitation Functional splinting Traumatic brain injury Pediatric Assessments Neurodevelopmental testing Developmental screening Sensory-motor testing Visual perceptual testing Feeding/swallowing/oral motor Seating & positioning assessment (i.e. w/c) Other Assessments Physical capacity evaluation Home assessments/home accessibility Activities of daily living Driving evaluation Cognitive/perception Treatment Approaches ADL Cognitive retraining Community re-entry Energy conservation/work simplification techniques Functional transfer training Home safety Lymphedema management Orthotics/Prosthetics training Cross Country Healthcare, Inc. Rev. 03/13 F0067 Occupational Therapy 2 of 5

3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Treatment Approaches - cont. Patient, family & staff training PNF SI Therapeutic exercises/activities Work hardening Splinting Neurodevelopmental testing (NDT) Incontinence management Modalities Anodyne Biofeedback Electrical stimulation Feeding techniques Fluidotherapy Oral motor facilities Paraffin bath TENS Therapeutic pool Ultrasound Prosthetics/Orthotics UE prosthetics Static splints Dynamic splints Serial casting Other Burn management Cardiac rehabilitation Cognitive retraining Computer skills FIM scoring Geriatrics Group dynamics IEP skills Cross Country Healthcare, Inc. Rev. 03/13 F0067 Occupational Therapy 3 of 5

4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Other - cont. Inservice education Job task analysis Therapeutic media Knowledge of payment sources Medicare Medicaid MDS General Skills Patient/family teaching Patients in isolation Patients in restraints Initial evaluation Lift/transfer devices Specialty beds End of life care/palliative care Computerized Charting Cerner EPIC McKesson Meditech National Patient Safety Goals Accurate patient identification Effective communication Pain assessment & management Infection control Universal precautions Care of patients in isolation Minimize risk of falls Prevention of pressure ulcers Age Specific Competencies Infant (birth to 1 year) Toddler (ages 1-3 years) Preschooler (ages 3-5 years) Childhood (ages 6-12 years) Cross Country Healthcare, Inc. Rev. 03/13 F0067 Occupational Therapy 4 of 5

5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Age Specific Competencies - cont. Adolescents (ages years) Young Adults (ages years) Adults (ages years) Older Adults (ages years) Elderly (ages 80+ years) Please list any Additional Skills: Additional training: Additional equipment: Fax to: The information on this and all preceding pages is true and correct. Signature Date 2012 Cross Country Healthcare, Inc. Rev. 03/13 F0067 Occupational Therapy 5 of 5

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