Initial Eval Data Ohana OT
Mary Koska walks through an evaluation form she built for pediatric OT that captures demographics, diagnoses, functional domains, and assessment scores in one place. The form feeds directly into JotForm reports and keeps detailed notes organized so she can write them fast. She offers the template for about $29.
Questions this video answers
Mary Koska (Ohana OT).
YouTube video (single-speaker demo).
Approximately $29.
Often starts 8–10/10 and reduces to about 2–3/10 by discharge.
Wilbarger deep pressure protocol.
Hey everyone. Mary Koska here with Ohana ot and I just thought I'd show you a system that I developed, a form I developed to help me organize all the information prior to an eval and during the eval. That helps me be really organized to write up my report really fast on jotforms. So it's the step before I showed you guys what the jotform looks like and I'm just going to show you how I organize myself. Okay. So first it just has the basic information. Since my jotform report is very fast to type up. I like just having a record of all of this stuff that's a little bit more in depth. So then I have a way of going back and seeing what all I actually did or if anybody ever wants more in depth information, I have it. Because if you saw my report, my jotform, it's pretty fast. It's more of a summary I guess. So I have the demographics, I like to have it documented that who contacted us with concerns and when the prescription is dated and if it was to evaluate and treat all of that. And I just have a check off sheet for common diagnoses that they have or if it's a different one. And then I have a whole list of these treatment diagnoses what I might be treating. And it's really common that I would do the weakness, the coordination and the unspecified disorder of the nervous system which is in here somewhere. Oh, there it is. That one is pretty common, common one that I'll use. And then you can see there's this block here. And this is really what I end up using to write all my goals. So as I'm reading we have a pretty thorough intake information that the parents fill out. And then there might be things that they mention while I'm talking with them during the eval. And then there's also information I'm drawing on from the sensory processing measure or if they did the, if they did the PDI or the real for the real for the adl. So up here I've got anything related to safety. I always like in my report to have something about safety. It helps justify medical necessity. So I just have all these different areas that relate to safety. Like really common would be he listed danger, physical aggression, temper tantrums, outbursts, that kind of thing. We don't focus on academics, but I like to just kind of note if there's academic concerns and then fine motor, if the issues around handwriting, if it's strength, coordination, speed, pressure modulation, grasp or in hand manipulation problems self care. I just have the general categories here but I'll usually know what the problem is like if they need a certain amount of assist or if they need reminders or whatever. The issue is and most common way it's written in here is feeding like being really picky and then grooming is a real common one that they're oversensitivity to hair, nails and teeth. Care gross motor. I have these common things falling out of the chair, falls with running, can't sit still. Overly active endurance or there's sedentary seeker, that kind of stuff. Cognitive it's usually attention, task completion, coping with transitions real common. Following multi step directions is a really common problem. Sensory in here I'm usually kind of summarizing what I'm getting off the spm. So I might just put like that they're oversensitive to what's common would be oversensitive to auditory, tactile and visual and sometimes smell and sometimes taste and just anything else. And then the social and play. I just check off anything that the parents noted and I like to you know, note like how they're doing in the community if they have problems tolerating those environments. So when I'm all done dumping stuff in here and it's really fast because I'm just doing check marks mostly like I said, when I go to write my goals, I'm taking them right off of here. Okay. The other page is what I'm looking at when I'm doing the eval. So I will, I will note any kind of red flags, things that might limit their progress or just anything I'm going to want to significantly note in the report. So if they're in foster care, multiple placement or they're on medications or just any kind of medical stuff, I'll note that there, there's kind of some things if they have other diagnoses and then I really try to hone in on what is their highest priority for a goal. You know, what's something that they can't do that they really want to be able to do. And then I just empathize with them and let them know what I think we can fix, what I think we can help with. So I just note that. And then these are going to be my highest priority goals. So I have the, the primary functional impairment the highest priority couple goals. And then I have all the other ones that come off that sheet. And then here we do apparent concern level at the beginning and at discharge. And so you know, a lot of times they'll have an 8, 9 or 10 out of 10 concern level at the beginning and usually it's like a 2 or 3 by the end of discharge, pre test treatment and post. When I do an eval I do some kind of pre and post test. So it might be like how long can they sit for? And then a test treatment. So it might be like Wilbarger Deep pressure protocol or it might be some other prop activity or it might be a vestibular activity. And then I note how it impacted them. And that gives me an idea if, if what we're going to do is going to be beneficial to them, then this section is where I do all my AERS clinical observations and I'm going to just check off if they're within normal limits, not tested, or if there's impairment. And then for each of these I have what it's looking at. And then I also have the norms. A four year old can do 10 seconds and then some key reflexes that I like to test. And then if I did do some kind of, oh, there is a typo there, I gotta fix that. If I did some kind of standardized assessment, I would note it, I would just check it and then I would just note this main scores and then I just sign it. And then that way I have a pretty thorough thing that I can go back and look at. If anybody ever wants more in depth information, I'm gonna flip this around and that made me feel better about having such a short report because I really just keep it really simple and put the main things in it that it needs. But if I ever needed to go back and see more in depth information, more my data and all that kind of stuff, I have this to go back on and that's how I do it because I just needed one place to kind of like funnel all the stuff I'm getting from my eval from the parent during it and all the stuff beforehand and then all the stuff from the sensory processing measure. So I just needed collective place that I could very efficiently organize the information and then be able to pull my goals out of it and my treatment plan. So that's how I do it and it's pretty fast. Oh, and the other thing is if anybody's wanting a copy of this, I think because it did take a lot of years developing and refining and changing it over and over, I can make it into a product if anybody wants it. And it would be like $29 or something like that. So if you want me to do that, I would be happy to do that, or you can get probably quite a bit off the video and make your own something similar. Okay, Have a good day. Bye.
