hello guys it's your girl lovely ot i am back with another video this video i am going to break down the steps in how to basically evaluate a patient how to come up with goals for a patient how does that process look like my whole goal with these videos is to make it as short as possible so that you can get straight to the point and get the meat and apply to your clinical applied to your job if you're working um so i'm gonna make it very very simple so what do you do with a patient how do you start how do you build a occupational profile so how do you come up with goals for your patient this video is going to help you to do just that so usually when i see a patient since i work with the adult population i'm going to focus a lot on that um because that's what i do right i work with the geriatric population in a skilled nursing facility and also in assisted living facilities so usually when i meet a patient i will build what we call an occupational profile which is basically um me trying to find out about the patient who they are what do they do things like that what is meaningful to them what are their roles you can also do this by reading the patient's chart just to get a little background um medical diagnosis what surgeries have they had things like that so you're basically building a profile for your patient to get to know them do you drive you know asking them those questions so that you can get to know them have a visual of who they are what they do and you also want to have a visual of their medical diagnosis as well just in case there's any precautions anything that you have to take a note off um anything that might be really good for the intervention you want to know the diagnosis you want to know the past diagnosis and also the present diagnosis as well all right so once you do that um you also want to ask them what they like to do because you can incorporate a lot of things in your sessions based on these answers so pay attention take notes if you need to and then use that information to help you with your interventions so once you have a pretty good idea about your patient who they are what's going on with them things like that you want to then come to the next question which is very important what are they having a problem with what are they trying to do but they're not able to do okay you want to ask this patient this what's going on you really want to ask this patient these questions like what's going on at home um what are you what were you able to do before that you're not able to do now what are you having a problem with you really want to get to the bottom of the problem and see where the problem is coming from so you can kind of have an idea where to start from for example if your patient says hey i cannot um when i go to use the toilet i cannot get up from the toilet or i cannot put my pants on after after i use the bathroom then you kind of have an idea and then you can ask some follow-up question why is that are you is it weakness do you think that you're weak are you not able to reach down and grab it what's the problem is the toilet seat too low you want to ask those questions just to have an idea of course of course the next thing that we're going to do after asking those questions is to do an assessment so i love to ask all these questions just so i can have the background and it's also really good for me to know if the patient know that they have a problem because sometimes patients really don't know that they have a problem and so by you having that conversation you can kind of be on the same page about what they think the problem is versus me just thinking that they have a problem when maybe they really don't maybe they're cool with not being able to get out of the toilet or maybe they have someone at home who helped them so i really want to ask those questions so that i can know where the problem is coming from and then we can go ahead and move on to the next thing now another thing to take note of too is that if the patient is unable to tell you what is wrong with them because of maybe a cognition problem or anything like that you can certainly ask their poa you can it might be a caregiver it might be a family member just ask them so that they can give you a little background about what the patient was able to do at home versus now so that we can kind of know what we are working towards sometimes when you call family members and you ask what the patient's plof was which is prior level of function was before the hospital or before the injury or before the diagnosis they can give you a pretty good idea and then you can know where to start from or where the end goal should be another really important question that i love to ask my patient is what are your goals what do you hope to achieve and they most of the time they can tell you pretty much like what they would like to do and of course i can keep this in mind when i'm building the goals for them so that i can make sure that what is important to them is what we are working on together now after you get the background and all of that information about your patient you want to do your assessment obviously right you want to do your full-blown assessment assess the patient biomechanics the strength range of motion and then you want to also start to assess some functional stuff like having them do some self-care stuff to see if they're able to do it having them do some functional mobility transfers to see if they're able to do it and if they're not able to do it then we know where the problem is correct however if the patient is able to do it maybe they can't do it but it's just not safe so then you can give them some safety um so then the goal would be based on safety instead of based on physicalities if that makes sense so that's all things that's why assessments are so important you have to assess the person's physical part and also their cognition as well i always do it simultaneously because i want to know even if the patient have the physical aspect i want to make sure that they are safe doing it and they don't have like attention issues or memory issues that may be impacting their ability to do their daily activities so always make sure that you look in the physical but also looking at the cognition as well so after i do all my assessments then it's time for me to go back and create a goal for the patient like i mentioned before make sure that you ask the patient if they're able to convey to you what their goals are then definitely ask them what their goals are for therapy and then you can keep that in the back of your mind when you're coming up with goals for the patient so another thing that i wanted to add is that if you're unable to assess something like let's say lower body dressing for whatever reason you can definitely make a note of that and make sure that you do that the next time that you see the patient so you can have a full-blown assessment of the patient what they're able to do and what they cannot do sometimes they can tell you if they have the cognition to be able to tell you even if you don't get to do it with them but for sure try to assess it just so you know where the problem is coming from just so you can have a better idea of where you're starting from and what's needed so they can reach their goals and they can return back to whatever it is that they wanted to return back to if this video was helpful definitely let me know if you guys want me to do another video on interventions a very general um summary about interventions and how i started and things like that definitely let me know down below and i can do that in the next video if you have any questions definitely go ahead and ask please make sure that you follow me on instagram lovelyot on instagram because i do a lot more on instagram and i'll hate for you guys to miss it if you have any other if you have any other video ideas that you would like for me to make definitely leave that down below as well i have an ebook that i have created it's an occupational therapy blueprint for anybody interested in becoming an occupational therapist that link will be that link will also be added in the description box as well and yeah thank you guys so much for watching and i'll see you in the next video bye guys