Finding yourself being asked to provide additional information in your reports once submitted to the referral source at a Canadian Forces base? I am sure you want to avoid this!
Here is a basic structure you can follow if you are writing an initial, comprehensive report for the Canadian Forces Health Services (these are NOT standards for Veterans Affairs Canada occupational therapy services).
Please note that not every initial report requires all these sections. In fact, only include information (background, assessment descriptions and details etc.) that is relevant to recommendations and referrals or required to assist the member and the health care team to make decisions on care.
What is very important is the recommendations page. It’s design, accuracy and the medical justifications provided are what multiple Canadian Forces Health Services Personnel will review to make plans and move care and rehabilitation forward.
Suggested Basic Structure
- Introduction: Members name and rank, age, and referral source
- Assessment / referral purpose
- Statement of your qualifications (in light of the referral purpose)
- Consent obtained from member
- Documentation reviewed prior to assessment
- Pertinent illness and/or injury information
- Pre-illness and/or injury medical history: diagnoses, surgery, medical precautions
- Current medical management and rehabilitation: professionals, medical precautions, and medications (pre and post)
- Future referrals/assessments as noted by the member and the health care team
- Current environment: Home layout/description (if you are specifically conducting a home modifications assessment – often seen as “major home modifications” – this section would be very detailed. In a later post an example of a comprehensive major home assessment will be provided – stay tuned!)
- Present complaints: Physical, cognitive, affective, etc.
- Self-report screening tools (description of the tool in brief and the results)
- Social support and caregiver situation
- Physical screening used and results
- Cognitive screening tools used and results
- Visual and hearing screening used and results
- Functional Status: positional and physical tolerances, functional lifting and carrying, Activities of Daily Living and Instrumental Activities of Daily Living, past and current leisure activities, past and current vocational/education situation, past and current driving situation, past and current sleep patterns etc.
- Itemized recommendations with medical justification/need/rational for each recommendation. The medical needs identified for each recommendation are found within the contents of your report (as above). Often, each recommendation will have medical information (symptoms, diagnosis etc.)
- If you are placing a recommendation for a specific occupational therapy program you will be offering you must ensure a) that there is noted medical need / justification for the program (as shown through baseline measures, assessments or expert observations) and b) the program specifically targets the persons occupational deficits and the techniques used utilized the member’s strength. All recommended OT programming must have (1) a description of the service/program, including reference(s) to the evidence, (2) what is the overarching goal / what will be accomplished, (3) the baseline measures used (this shows need for the program), (4) expected outcomes, (5) overview of the time line and (6) has the member agreed to participating in the program? Do they understand the time commitment etc.?
- The above descriptions are required for programs that are (1) structured, formal programs such as the Progressive Goal Attainment Program or (2) directly related to a specific referred need (i.e., four pain management / energy management occupational therapy sessions).
- New report section: The Occupational Therapy Redacted Recommendations Report (OT-RRR): See last weeks post on this!
Don’t forget to review your colleges reporting structure and requirements as well. Speak with the local CAF health care team as well. Ask: what do they want to see? how can your report be best organized to assist them to quickly move your recommendations forward?
Are we missing something important? If so, let us know!