Assessments - Clinicians

Assessments are an essential part of the occupational therapy process. They are used for many purposes, including:

• To support development of goals

• To measure baseline and progress data (especially for NDIS purposes)

• As part of Functional Capacity Assessments (FCAs)

• To analyse skill challenges impacting Occupational Performance Issues (OPIs)

What to do When an Assessment is Needed

When you flag that an assessment may be necessary, follow these steps:

1. Highlight with the parent/caregiver that you think an assessment might be necessary/helpful. Provide a quick overview of what the assessment is and why it might be needed.

2. Inform the parent/caregiver about the cost of the assessment:

   • Often assessments are completed with session time, meaning the participant will be invoiced just like a usual session. If a session is booked in addition to the usual session, it will be invoiced at the hourly rate ($193.99).

   • The time it takes to score and analyse the assessment is also invoiced. This is put through your 'Report Tracking' spreadsheet, combined into one entry with the report writing time.

   • If the parent/caregiver would like a report, this is also invoiced at the hourly rate ($193.99). Report time estimates can be found below

     • Reports are generally expected for most assessments, however, if funding is tight, the report might be skipped. Instead, a summary email may be sent to the necessary stakeholders instead. 

3. Request admin to book an additional session to complete the assessment if needed (inform admin whether this is a parent-only or with the participant)

4. Complete the assessment as per instructions below.

5. Score the assessment, keeping track of the time it takes

6. Write the assessment report using the template found in the OneDrive

   • C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports

7. Send the report to the Senior OT to be edited if needed

8. Email the report to the parent/caregiver so they have a copy. Also consider whether there are other key stakeholders who need a copy (NDIS contact, teacher, other therapists etc.)

   • Dear [parent name]

Attached is [client's name]'s [assessment name] report.
Please don't hesitate to reach out if you have any questions or concerns.

Kind regards,
[Clinician name]

• Enter the time taken into your 'Report Tracking' spreadsheet.

• Discuss assessment results with the parent, either in their next session or book an additional session via the most appropriate method (e.g. in-person, phone call, Teams call)

Q-Global is the online platform that allows you to administer digital versions of some assessments and create reports. 

When you first start at Joyful Journey OT, you will receive your Q-Global log in details via email. If this is not the case, please speak to your direct supervisor.

Adding a client to Q-Global

1. Make sure you search first to see if the client has already been added by another clinician. If not, then:

2. Click 'New Examinee'

3. From their Halaxy information, add the client's 

   • First Name

   • Last name

   • Gender* (Optional)

   • Birth date, and

   • Email* (Optional)

You have now added the client.

Assigning an assessment on Q-Global

4. Search for/locate and click on the name of the client from the list of clients on the main screen

5. Select the 'Assign New Assessment' button

6. In the pop-up search box, type in the name of the assessment you need and select it, clicking 'Assign' at the bottom of the pop-up window

7. Select your preferred 'Delivery Option'

   • Paper Form: select if the assessment has already been completed on paper and you are entering the answers to auto-score and generate a report

   • In-Person Online: select if you are completing the assessment with the client/parent live (ie. in person or on Teams/a phone call)

   • Send Link via E-mail: select if you want to send the assessment to a parent/caregiver/teacher etc. to complete independently 

     • Fill in the details of the person being sent the link (ie. the parent's name or the teachers name)

8. If you are setting up the assessment ahead of time, click 'Save and launch/send later' (launch or send will show depending on the Delivery Option selected).

9. When you are ready to complete/send the assessment, click the orange button (Launch Assessment OR Continue to E-mail

Emailing an Assessment

1. After selecting 'Send Link via E-mail' and clicking the orange 'Continue to E-mail' button as per above;

2. You can select to either 

   • Send via Q-Global's email: this will automatically send an email to the listed email address with the link embedded, however, the parent/teacher/client may miss this as it is likely to go to junk

   • Use your own email: This will give you a link to copy and paste into your own email. It is recommended that when you write the email to send to the parent/teacher/client, that you inform them that the link will expire after 30 days.

     • If you have no response 2 weeks after sending the link, I recommend sending a follow up/reminder email

Generating a Q-Global Report

1. Once an assessment has been completed, you will receive an email from Q-Global with the Subject line: 'Q-global Completed Assessment Notification'

2. Log in to Q-Global and select the client from the client list

3. In the assessment table the assessment 'Status' will say 'Ready for Reporting'

4. Click on the assessment you want to generate a report for in the table

5. Check that the information is correct and the relevant fields are filled in

6. Click 'Generate Report'

7. Select the report type you need (usually there is only one option)

   1. If the 'usages available' is zero (0), contact your direct supervisor to request more. You cannot continue until their is at least one (1) report usage available.

8. Download the report as a Word Docx (It is easier to convert word to a pdf than the other way around if needed)

9. After the report has downloaded, save a copy in the client's OT folder on the OneDrive

NB: Do not send this Q-Global report to anyone outside the clinic. It is copywrited. You will use the information in the downloaded report to write your own report on a Joyful Journey template.

The Sensory Profile is a standardised measure of sensory preferences. The assessment has a toddler version (0-2:11 years), a child version (3-14 years), adolescent/adult version (11+ years) and a school companion version. The toddler and child versions are completed by/with the parent/caregiver, the adolescent/adult version is self-reported by the client, and the school companion assessment is completed by a teacher with good knowledge of the student. 

Time:

• A Sensory Profile can be sent home (paper or digital copy) to be completed by the parent/caregiver/teacher independently, at no financial cost to themselves. 

• A Sensory Profile completed with the therapist (via zoom or in-person) usually takes one (1) hour, sometimes up to 1.5 hours if the parent/caregiver is a talker.

• The Sensory Profile report usually takes one (1) hour per form (i.e. if a child and school companion form are completed, the report may take 1.5-2 hours total)

• Time total: 1-3 hours

Important Notes:

• Do not select '0' or 'Does Not Apply' unless the client has a sensory loss (i.e. they are deaf so the 'auditory' questions don't apply.

• If you send the assessment with a parent/caregiver to complete independently, instruct them of the above point.

• Everyone on the planet has different sensory preferences, so would have a unique Sensory Profile. Differences in sensory processing are not bad or a sign that there is an issue. This assessment is just informative.

Writing the Report

• The Sensory Profile template can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X - Child Sensory Profile 2 Report - 2024.docx"

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

• Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

Word Doc Template:

1. If you are unable to make edits to the document, ensure that at the top-right of the document, it says 'Editing' and not 'Reviewing'

2. Enter all client-specific background information

3. To replace terms:

   • select CTRL+H on your keyboard

   • Type in the word you want to change in the first field box

   • Type in the word you want it replaced with in the second field box

   • Click 'More'

   • Tick 'Case sensitive'

   • Click 'Replace all'

     • E.g. Change [CLIENT] to John; [his/her] to his etc.

     • NB: Make sure to include the [square brackets] in the first field box

4. Anything in red font in the template needs to be altered to be client-specific

Child Sensory Profile

5. Use the Q-Global downloaded report to check which cells to put X in under 'Assessment Results' for all three (3) tables

6. Under 'Interpretation' and 'Sensory Patterns', you will notice the first paragraph is essentially repeated x3 times, with the terms 'much more than others', 'just like the majority of others' and 'much less than others' swapped out. Based on the results in the tables, keep the paragraph that aligns to the correct score, and delete the other two.

   • If the results are 'just like the majority of others', you do not need to list the answers underneath, and can delete the examples/dot point list underneath that section. 

   • If the results are 'much more than others', 'more than others',  'much less than others' or 'less than others', you will need to list the relevant results from the assessment questions. Using the Q-Global report, look for the corresponding questions marked '4' or '5' (much more/more than others) or '1' or '2' (much less/less than others) and delete the rest of the dot points/items that are not contributing to that score.

7. Repeat for all sections within 'Interpretation'

8. You will find many pre-given recommendations listed under 'Recommendations'. Please read through and delete irrelevant ones

9. If the score for any section was 'just like the majority of others', you are unlikely to need the recommendations listed for that section.

10. Please add additional recommendations based on your clinical reasoning, specific comments offered when administering the assessment and your knowledge of the child

11. Sign the report when finished

12. Send the report to your direct supervisor for editing if required/wanted

13. Save the report as a PDF with the following naming convention:

    • D.L - Sensory Profile Report - 07.2024

14. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

Sensory Profile - School Companion Form

15. Use the Q-Global downloaded reports (both the Child and School Companion Reports) to check which cells to put X in under 'Assessment Results' for all four (4) tables

16. Follow the same instructions for the Child Sensory Profile report (above), ensuring that you use the results from the correct forms for each section.

17. The School Factors section is completed the same way as the Sensory Domains and Behavioural Domain sections. Ensure that the explanation in each School Factor paragraph makes sense given the child's specific response (e.g., if they scored 'just like the majority of others' for School Factor 1, then it does not make sense for the paragraph to say they may need additional supports while at school'. 

    • School Factor 1 = Seeking + Registration

    • School Factor 2 = Seeking + Sensitivity

    • School Factor 3 = Avoiding + Sensitivity

    • School Factor 4 = Avoiding + Registration

18. For the recommendations section, it is a good idea to include home- and school-based recommendations based on the results for each form. 

19. If the score for any section was 'just like the majority of others', you are unlikely to need the recommendations listed for that section.

20. Please add recommendations based on your clinical reasoning, specific comments offered when administering the assessment and your knowledge of the child

21. Sign the report when finished

22. Send the report to your direct supervisor for editing if required/wanted

23. Save the report as a PDF with the following naming convention:

    • D.L - Sensory Profile + School Companion Report - 07.2024

24. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

Adult/Adolescent Sensory Profile Form

25. Use the Q-Global downloaded report to check which cells to put X in under 'Assessment Results and Interpretation' for Table 1

26. Use the scores on the second and third page of the downloaded Q-global report to determine which paragraphs of the 'Sensory Quadrant Pattern Interpretation' need to be kept and which ones need to be deleted to be relevant for the given client for each Sensory Pattern (Seeking, Avoiding, Sensitivity and Registration)

27. Use the spreadsheet found below to enter the raw scores of the assessment into cells C9:C68. This will then populate the rest of the spreadsheet to allow you to complete the 'Sensory Stimuli' table in the Word Doc.

    • C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\Assessments\Sensory Profile (ADULT) Excel Score Sheet with Interpretations.xlsx

    • Note that:

      • Sensation Seeking = High Neurological Threshold + Active Behaviour Response

      • Sensation Avoiding = Low Neurological Threshold + Active Behaviour Response

      • Sensory Sensitivity = Low Neurological Threshold + Passive Behaviour Response

      • Low Registration = High Neurological Threshold + Passive Behaviour Response

28. You will find many pre-given recommendations listed under 'Recommendations'. Please read through and delete irrelevant ones

29. If the score for any section was 'just like the majority of others', you are unlikely to need the recommendations listed for that section.

30. Please add additional recommendations based on your clinical reasoning, specific comments offered when administering the assessment and your knowledge of the client

31. Sign the report when finished

32. Send the report to your direct supervisor for editing if required/wanted

33. Save the report as a PDF with the following naming convention:

    • D.L - Sensory Profile Report - 07.2024

34. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

The Vineland Adaptive Behaviour Scale (3) is a standardised measure of adaptive behaviour, defined as the collection of conceptual, social, and practical skills learned by people to enable them to function in their everyday lives. The assessment has a domain and comprehensive assessment type, with the domain being shorter and more surface level, and the comprehensive assessment being much more involved and longer. There are also Parent/Caregiver forms, Interview Forms and Teacher Forms. It is generally recommended to use the comprehensive Parent/Caregiver form and/or comprehensive Teacher form. The assessment can be used on any people of any age.

Time:

• A Vineland can be sent home (paper or digital copy) to be completed by the parent/caregiver/teacher independently, at no financial cost to themselves. 

• A Vineland can be completed with the therapist (via zoom or in-person) usually takes 90 minutes (1.5 hours), sometimes up to 2 hours if the parent/caregiver is a talker.

• The Vineland report usually takes 90 minutes (1.5 hours) per form (i.e. if a Parent/Caregiver and Teacher form are completed, the report may take 2-3 hours total)

• Time total: 1.5-3 hours

Important Notes:

• The Vineland can assess Motor Skills (Fine and Gross Motor) for children 9-years-old and under.

• The Vineland assessment measures maladaptive behaviours, which on the Parent/Caregiver form can include ‘heavy’ questions such as ‘has your child ever talked about or attempted to take their own life?’. It is a good idea to warn a parent before starting the ‘Critical Maladaptive Subtest’ that there are heavy questions but that they are necessary to ask for the assessment.

• If you send the assessment with a parent/caregiver to complete independently, instruct them of the above point.

• It is strongly recommended that you complete the assessment questionnaire on Q-Global, whether in person or sent home, as scoring the paper form is complex and time consuming.

Writing the Report

• The Vineland template can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X – Vineland Comprehensive Report - 2024.docx"

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

• Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

Word Doc Template:

1. If you are unable to make edits to the document, ensure that at the top-right of the document, it says 'Editing' and not 'Reviewing'

2. Enter all client-specific background information

3. To replace terms:

   • select CTRL+H on your keyboard

   • Type in the word you want to change in the first field box

   • Type in the word you want it replaced with in the second field box

   • Click 'More'

   • Tick 'Case sensitive'

   • Click 'Replace all'

     • E.g. Change [CLIENT] to John; [his/her] to his etc.

     • NB: Make sure to include the [square brackets] in the first field box

4. Anything in red font in the template needs to be altered to be client-specific

5. Estimated responses: the percentage of estimated responses can be found at the top of page 9 of the Q-Global report. Use the paragraphs in red to format your own paragraph about the percentage of estimated responses.

6. Use the Q-Global downloaded report to copy the ‘standard scores’ into the correct column. Delete the columns/sections that are not required (e.g. if you only completed a Parent/Caregiver form, delete the Carer Interview Form and Teacher Form columns).

7. Use the table on page 2 of the report template document (also found below and in the downloaded Q-Global report) to assign the ‘Adaptive Level’ category to Table 1. It is also recommended to colour the cell according to the adaptive level for quick reference and interpretation as per below:

Adaptive Level

Subdomain v-Scale Scores

Domain and ABC Standard Scores

High

21 to 24

130 to 140

Moderately High

18 to 20

115 to 129

Adequate

13 to 17

86 to 114

Moderately Low

10 to 12

71 to 85

Low

1 to 9

20 to 70

*Subdomain v-scale scores apply to expressive, receptive and written; personal, domestic and community, interpersonal relationships, play and leisure and coping skills; and fine motor and gross motor.

*Domain Standard Scores apply to Communication, Daily Living Skills, Socialization, Motor Skills and ABC. 

8. Repeat steps 5 and 6 for Table 2

9. For the Critical Items listed under Table 2, reference the list found on page 6 of the Q-Global downloaded report, paying attention to whether they were scored as (often) or (sometimes).

10. Strengths and weaknesses can be found in the tables on page 4 of the Q-Global report, listing them under [STRENGTHS] and [WEAKNESSES] in the template document.

11. For the Interpretation section, use Table 1 from the template document, as well as the Percentile Rank information found at the top of page 4 of the Q-Global report, to complete the second paragraph under each Domain in the template document.

12. For each subdomain, you will notice that all Content Areas are listed (e.g. for the written subdomain, prereading, developing reading skills, developing writing skills, applying reading and writing skills are all listed as both strengths and difficulties. Using the Intervention Guidance/responses list on page 11 of the Q-Global report, determine which Content Areas are strengths/mastered, and which require further support. You will notice that questions scored as a 0 or 1 are greyed out in the tables on the Q-Global report. The Content Areas corresponding to these letters will help you determine which ones require further support.

13. Repeat for each domain and subdomain.

14. Maladaptive Behaviour is completed in a similar way, using Table 2 and the responses for Maladaptive Behaviour Items at the end of the Q-Global report, noting whether they were scored as often (2) or sometimes (1).

15. Use the Clinical Implications section to summarise the results and potentially list updated goals based on the results.

16. Use the headings to list recommendations based on the Vineland results.

17. Sign the report when finished

18. Send the report to your direct supervisor for editing if required/wanted

19. Save the report as a PDF with the following naming convention:

    • D.L - Vineland Report - 07.2024

20. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) is a standardized assessment designed to measure a variety of gross and fine motor skills in individuals ages 4 through 21 years. The assessment takes place in the clinical setting, and scores are then normed referenced with same aged peers.

The BOT2 assesses four motor area composites, each comprising of two subtests:

o   Fine manual control

§  Fine motor precision

§  Fine motor integration

o   Manual co-ordination

§  Manuel dexterity

§  Upper limb co-ordination

o   Body co-ordination

§  Bilateral co-ordination

§  Balance

o   Strength and agility

§  Running speed and agility

§  strength

Time:

• As the BOT-2 is completed with the client themselves, it must be completed in person and the administration time is dependent on the child’s engagement. The BOT-2 often takes two (2) to three (3) hours to complete.

• Dependent on the client and scheduling, this can be completed in one, two-hour appointment, or over two one-hour appointments.

• If the BOT-2 is manually scored, the scoring, interpretation and report usually takes 2 hours to complete, however, if the scores are entered into Q-Global to calculate digitally, the report takes 1-1.5 hours to complete.

• Time total: 3-5 hours

Important Notes:

• As the BOT-2 is a motor skills assessment, it is strongly recommended that you role-play each item before your first administration.

• As the BOT-2 is such a long assessment, it is often recommended to provide a visual schedule that the child can tick off the subtests as they go, with a small break between the first and third subtests, and a bigger break in the middle of the assessment if being completed in one long session.

• The BOT-2 has a ‘short-form’ version to complete, however, it is usually expected that you would complete the long-form version.

• It is strongly recommended that you input the raw scores from the BOT-2 into Q-Global to save time and ensure accuracy with scoring.

Administering the Assessment

• Preparing the area for administration

  • You will need:

    • 1 table

    • 2 chairs (1 for examinee to rest his/her feet on floor comfortably)

    • Tape 50 foot line on floor that includes a start/finish line, an examiner throwing line, and an end line.

    • Determine preferred hand and foot – Instruct the examinee to draw a line on a sheet of paper using a pencil. Regard the hand he/she uses as the preferred drawing hand.
      Set the tennis ball and instruct the examinee to pick up and throw the ball to you. Regard this hand as the preferred throwing hand/arm.
      Place the tennis ball on the floor and instruct the examinee to kick the ball. Regard the foot he/she uses as the preferred foot/leg.

• Kit and additional equipment

  • Stopwatch

  • Tape measure

  • Red pen/marker/pencil

  • Balance beam

  • Kit (including administration manual and subtest items)

• General directions

  • Erasing is not allowed on any item using the pencil.

  • Make sure to sharpen the pencil before testing begins, and resharpen the pencil as needed during testing.

  • Before administering each item, teach the task to the examinee using verbal and nonverbal directions as necessary to ensure the examinee’s understanding of the task.

Writing the Report

• The BOT-2 template can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X – BOT-2 Complete Report - 2024.docx"

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

• Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

• When creating the report on Q-Global, you can choose to enter either the raw scores or the standard scores. Additionally, it is recommended to include (tick) all boxes of information in the report before generating the report.

Word Doc Template:

1. If you are unable to make edits to the document, ensure that at the top-right of the document, it says 'Editing' and not 'Reviewing'

2. Enter all client-specific background information

3. To replace terms:

   • select CTRL+H on your keyboard

   • Type in the word you want to change in the first field box

   • Type in the word you want it replaced with in the second field box

   • Click 'More'

   • Tick 'Case sensitive'

   • Click 'Replace all'

     • E.g. Change [CLIENT] to John; [his/her] to his etc.

     • NB: Make sure to include the [square brackets] in the first field box

4. Anything in red font in the template needs to be altered to be client-specific

5. Table 1: It is strongly recommended to remove the ‘age-equivalents’ column as they are not very helpful or accurate and are often not nice to read as a parent.

6. Use the Q-Global downloaded report to copy the information into the correct columns. Colour the final column (descriptive category) according to the level for quick reference.

Well-Above Average

Above Average

Average

Below Average

Well-Below Average

7. Interpretation: Using the information from the table (either from the Q-Global report or from your report template), change the term in bold to the descriptive category label, and insert the percentile rank. Remove the sentence in each paragraph referring to the age-equivalence. With reference to the scores in the BOT-2 form and comments on how they engaged and performed in each item, write a couple of sentences about the child’s strengths and challenges for each subtest. Consider things such as:

   • How much instruction was required (verbal, modelled, visual)

   • Any modifications made to the item

   • How many attempts it took

   • If they engaged well or required a lot of encouragement and motivation (give details if so)

   • Which skills seemed to be easy or mastered

   • Which skills seemed to be a challenge or not yet mastered

8. Personal strengths and weaknesses: You will find a paragraph towards the end of the Q-Global report labelled ‘Personal Strengths and Weaknesses’. Use this information to write a paragraph outlining the strengths and weaknesses in the word doc.

9. Notes and observations: this section can be as long or short as needed based on how much information you have to comment on, and whether you included more in the interpretation section or choose to comment on it here.

10. Summary and implications: Give a general overview of the results, and how they link to functional challenges the client is experiencing. It is also a good idea to comment on why the assessment was completed, and link it in here (e.g. if you completed the assessment to determine goals, write new goals here. If you completed the assessment to compare to a previous assessment, add previous results here and comment on changes and the plan moving forward).

11. Sign the report when finished

12. Send the report to your direct supervisor for editing if required/wanted

13. Save the report as a PDF with the following naming convention:

    • D.L – BOT-2 Report - 07.2024

14. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

The Miller Function and Participation (M-FUN) Scales are a developmental assessment tool that assess a wide variety of children’s skills across several settings. Skills that are assessed in the M-FUN Scales include Visual Motor, Fine motor, and Gross Motor skills. Additionally, executive function and social participation are also assessed. These areas are assessed across the home and school environment as well as during the clinical assessment.  

The M-FUN assesses three areas:

§  Visual Motor

§  Fine Motor

§  Gross Motor

Time:

• As the M-FUN is completed with the client themselves, it must be completed in person and the administration time is dependent on the child’s engagement. The M-FUN often takes two (2) to three (3) hours to complete.

• Dependent on the client and scheduling, this can be completed in one, two-hour appointment, or over two one-hour appointments.

• The M-FUN is unable to be scored using Q-Global, so must be scored manually. Scoring typically takes up to one (1) hour and the report can take an additional one (1) hour.

• Time total: 4-5 hours

Important Notes:

• As the M-FUN is a motor skills assessment, it is strongly recommended that you role-play each item before your first administration.

• The M-FUN has a subtest that assess social skills using a snack. Consider what kid-friendly snack you will have available (e.g. crackers).

• Take notes on participation and effort throughout the administration.

• The M-FUN had a classroom checklist, which can sometimes take a lot of coordination to get done by the teacher, so plan ahead.

Administering the Assessment

• Preparing the area for administration

• • You will need:

• • • 1 table

    • 2 chairs (1 for examinee to rest his/her feet on floor comfortably)

    • Determine preferred hand and foot – Instruct the examinee to draw a line on a sheet of paper using a pencil. Regard the hand he/she uses as the preferred drawing hand.

    • Set the tennis ball and instruct the examinee to pick up and throw the ball to you. Regard this hand as the preferred throwing hand/arm.

    • Place the tennis ball on the floor and instruct the examinee to kick the ball. Regard the foot he/she uses as the preferred foot/leg.

• Kit and additional equipment

• • Stopwatch

• • Tape measure

• • Red pen/marker/pencil

• • Kit (including administration manual and subtest items)

  • Drink bottle with lid, cups and a snack that the client can eat (check allergies)

  • Record Form and Home Observations Checklist.

• General directions

• • Erasing is not allowed on any item using the pencil.

• • Make sure to sharpen the pencil before testing begins, and resharpen the pencil as needed during testing.

• • Before administering each item, teach the task to the examinee using verbal and nonverbal directions as necessary to ensure the examinee’s understanding of the task.

Scoring the Assessment

·         Circle the corresponding number next to each skill for each game whilst administering the assessment.

·         Sum the scores at the bottom of each column.

·         Transfer the summed scores to the Performance Raw Score Totals table (the first table) on the second page of the M-FUN Record Form.

·         Sum each column; Visual Motor, Fine Motor and Gross Motor, paying attention to the age in the Gross Motor column.

·         Using the Examiner’s Manual, Appendix B, calculate the Scaled Scores and transfer these into the first row of Table 2 (Norm-Referenced Performance Scores).

·         The second row of Table 2 is found at the bottom of the table you used in the Examiner’s Manual to find the Scaled Scores (Appendix B). Use the numbers assigned to 68% (90% and 95% are used for research purposes).

·         Using the numbers you just entered in row 2 of the Record Form, calculate up and down from the Scaled Score in row 1, and enter it into row 3.

·         The percentile rank can be found in Appendix C. Calculate the percentile rank for both row 1’s number and enter it in row 4, and row 3’s numbers and enter them in row 5.

·         It is not recommended to use the age-equivalents, as they are inaccurate, not helpful and often not nice to read, however, should you have reason to add them, they can be found in Appendix D. Use the raw scores calculated in table 1 of the Record Form and find them in the corresponding column, writing the age on the left of the column in row 6 of Table 2 in the Record Form.

·         You can also transfer the relevant data to the front page on the Record Form under Performance Scores and place an ‘X’ on the Performance Score Chart that corresponds to each Scaled Score. You can also draw a horizontal line at the top and bottom score of the Confidence Intervals and shade in the area between the two to indicate the area that the child’s score likely falls into.

·         Once the assessment administration has been finalised, complete the Test Observations Checklist on page 4 of the Record Form based on your observations during the assessment.

·         Transfer the scores from the Test Observations Checklist, the Home Observations Checklist and the Classroom Observations Checklist to the Participation Scores Table on the first page of the Record Form and tick the corresponding box using Appendix F from the Examiner’s Manual.

·         Finally, complete the Neurological Foundations Profile. This is done by circling the corresponding item numbers that received a score of 1 or 0 on pages 5-25 of the Record Form. Doing this allows you to see patterns in the scores and identify which skill areas need to be addressed in OT.

Writing the Report

• The M-FUN template can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X – M-FUN Report - 2024.docx"

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

• Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

Word Doc Template:

1. If you are unable to make edits to the document, ensure that at the top-right of the document, it says 'Editing' and not 'Reviewing'

2. Enter all client-specific background information

3. To replace terms:

   • select CTRL+H on your keyboard

   • Type in the word you want to change in the first field box

   • Type in the word you want it replaced with in the second field box

   • Click 'More'

   • Tick 'Case sensitive'

   • Click 'Replace all'

     • E.g. Change [CLIENT] to John; [his/her] to his etc.

     • NB: Make sure to include the [square brackets] in the first field box

4. Anything in red font in the template needs to be altered to be client-specific

5. Table 1: Use the Performance Score Chart from the first page of the Record Form to place an ‘X’ in the corresponding row for each subtest.

6. Interpretation: Fill in the data using the Record Form for each of Visual Motor, Fine Motor and Gross Motor. The descriptive categories listed are based on clinician interpretation, and not set numbers.

7. Comment on the child’s participation, modifications made to the tasks, additional support requirements, types of and number of instructions required to understand and complete tasks, and using the Neurological Foundations Profile to comment on strengths and weaknesses of different skills.

8. Similarly, complete the Participation Scores section, using the information from the first page of the Record Form. Compare the categories of the completed forms and comment on which categories appear consistently strong and challenging across the forms.

9. Summary and Recommendations: Give a general overview of the results, and how they link to functional challenges the client is experiencing. It is also a good idea to comment on why the assessment was completed, and link it in here (e.g. if you completed the assessment to determine goals, write new goals here. If you completed the assessment to compare to a previous assessment, add previous results here and comment on changes and the plan moving forward).

10. Sign the report when finished

11. Send the report to your direct supervisor for editing if required/wanted

12. Save the report as a PDF with the following naming convention:

    • D.L – M-FUN Report - 07.2024

13. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

The Brown Executive Function/Attention Scales (Brown EF/A Scales) provide an easily understandable, standardised tool to collect information about the problems an individual demonstrates or reports with executive functions, the self-management functions that support attention in multiple tasks of daily life. Results are compared with norms to indicate how any reported problems compare to other people of similar age. Below are the six clusters of executive functions assessed by the Brown EF/A Scales:

·         Activation: Organising, prioritising, and activating to work

·         Focus: Focusing, sustaining, and shifting attention to tasks

·         Effort: Regulating alertness, sustaining effort, and adjusting processing speed

·         Emotion: Managing frustration and modulating emotions

·         Memory: Utilising working memory and accessing recall

·         Action: Monitoring and self-regulating action

Time:

• The Brown’s assessment can be composed of multiple assessments, including:

  • Parent forms (ages 3-7, 8-12 and 13-18)

  • Teacher forms (ages 3-7 and 8-12)

  • Self-Report forms (ages 8-12, 13-18 and 19+)

• These assessments can be sent digitally on Q-Global and completed in the responders own time at no additional charge to the client’s funding.

• If completed in person, the questionnaires are still completed independently, and as the clinician, you would be there to read the questions on the form if needed, answer questions the responder may have and support in thinking through answers. The questionnaires should take no longer than an hour to complete.

• The report for a Brown’s typically takes 1 hour.

• Time total: 1-2 hours

Writing the Report

• The Brown’s EFA template can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X – Browns EF-A Scales Report Template (LONG) - 2024.docx"

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

• Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

Word Doc Template:

1. If you are unable to make edits to the document, ensure that at the top-right of the document, it says 'Editing' and not 'Reviewing'

2. Enter all client-specific background information

3. To replace terms:

   • select CTRL+H on your keyboard

   • Type in the word you want to change in the first field box

   • Type in the word you want it replaced with in the second field box

   • Click 'More'

   • Tick 'Case sensitive'

   • Click 'Replace all'

     • E.g. Change [CLIENT] to John; [his/her] to his etc.

     • NB: Make sure to include the [square brackets] in the first field box

4. Anything in red font in the template needs to be altered to be client-specific

5. Use the Q-Global downloaded report to copy the ‘T-scores’ and % Rank into the correct columns. The classification Label can be calculated using the table on page 2 of the word doc template. Consider colour coordinating the label column to support quick reference of the results. Delete the columns/sections that are not required (e.g. if you only completed a Self-Report and Parent/Carer form, delete the Teacher Form column).

6. Click on the Score Summary Chat, and select the tab at the top of the word doc that says ‘Chart Design’. Click on the ‘Edit Data’ drop down button and select ‘Edit Data in Excel’. This will open a new window where you can copy the T-scores in to create the chart. Once the data is all entered, click on the chart again and use the filter button that pops up on the right-hand side to select which form results you want to include in the graph.

7. Interpretation: Fill in the data using the T-scores, percentile ranks and descriptive labels for each paragraph. You can also compare and comment on the different scores for each form. If they are similar, this indicates that the results are reliable and the skill is either a strength, adequate or a challenge for this client. If the results vary, consider why this might be.

   • Masking as school

   • Difficulties with self-awareness from the child

   • High expectation of parents at home

8. Recommendations: Give a general overview of the results, and how they link to functional challenges the client is experiencing. It is also a good idea to comment on why the assessment was completed, and link it in here (e.g. if you completed the assessment to determine goals, write new goals here. If you completed the assessment to compare to a previous assessment, add previous results here and comment on changes and the plan moving forward).

9. Sign the report when finished

10. Send the report to your direct supervisor for editing if required/wanted

11. Save the report as a PDF with the following naming convention:

    • D.L – Browns EF-A Scales - 07.2024

12. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

The NDIS End of Plan Report assesses and summarizes a client's progress towards their therapy goals, reviews current performance, and makes recommendations for future support. This report is essential for updating the NDIS plan and ensuring that the client receives appropriate funding and services. Follow these steps to ensure that the report is comprehensive, clear, and aligns with NDIS requirements.

Time:

• The End of Plan typically takes around one (1) hour to complete. For complex clients, the report may take 1.5 to 2 hours to complete.

• Time total: 1-2 hours

Important Notes:

• To know when an End of Plan (EOP) report is due, reference your Report Tracking spreadsheet. This can be found by right clicking on the excel button at the bottom of the screen and selecting the pinned ‘Report Tracking’ document.

• In the document, you can change how much notice you receive for an EOP report. Click cell A1 in the tracker (“More Options”) and select ‘Settings’. In cell B2, select a number between 4 and 8. This will give you 4-8 weeks’ notice of a report being due. Note: this date is 6 weeks prior to the end date of the NDIS plan, as requested by the NDIS to allow them time to read the reports.

• An EOP that is due will automatically populate in your tracker, highlighted in yellow with the date it is due. It is recommended to check the tracker weekly.

• When you get a notification that an EOP report is upcoming, it is a good idea to talk about this with the parent/client, determine if any standardised assessments are required to support your EOP report, and to discuss what funding supports the clients would like in their upcoming plan.

Report Template and Setup

• Access the Template:

  • The M-FUN template can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X – NDIS EOP Report - OT - 2024.docx"

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

  • Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

• Editing the Template:

  • Ensure the document is in 'Editing' mode (top-right corner should say 'Editing' and not 'Reviewing').

  • Replace placeholder terms (e.g., [CLIENT], [PARENT]) using the 'Find and Replace' feature (CTRL+H) in Word.

  • Anything in red font in the template needs to be altered to be client-specific

Client Background Information

• Client Details:

  • Fill in the client’s names, date of birth, parent/guardian/carer, and NDIS number.

• Background Summary:

  • Include the client’s age, gender, living situation (who is living at home) and schooling details (school name, grade, frequency of attendance)

  • Mention hobbies, interests, and diagnoses that are relevant to the NDIS funding

  • Describe the frequency and setting of therapy services, including any important people involved

  • Note any issues related to service attendance or delays in accessing services

Change of Circumstances (if applicable)

• What is a Change of Circumstances?

  • A change of circumstances is often completed before the end date of a plan, when changes in the client’s life (carer changes, diagnosis changes, significant increase in behaviours etc.) mean that the current NDIS plan/funding is no longer sufficient or accurate to the client

• Details for Changes:

  • Provide information on any changes in the client’s condition or circumstances that affect their needs.

  • Include relevant assessments that support recommendations and justify why the NDIS should fund the support.

  • Discuss how these changes impact functional domains like physical, sensory, communication, cognitive, and behavioural needs.

Current Performance

• Performance Overview:

  • Insert details of any assessments or observations relevant to the client’s current performance.

    • Assessments: When including assessment results, include information such as:

      • 1-2 sentences on what the assessment is (remember, the person reading this may have never heard of the assessment)

      • When the assessment/s were completed and with who if relevant

      • The results (typically in table form) with the descriptive category/label if possible

      • 1-2 sentences summarising the results in plain language

      • 1-2 sentences outlining the functional impact or ‘so what’ of the results

    • Observations: This may include observations such as:

      • If therapy is provided in a DIR/Floortime model, an overview of this and what it is

      • Behaviours of concern

      • Additional supports required for engagement

      • A summary of their progress over the current plan

    • This is also where you should add relevant comments to justify what you will request later. For example, if the family have requested a Behaviour Support Practitioner, add a paragraph here outlining the behaviours of concern that justify a Behaviour Support Practitioner

Therapy Goals and Progress

• List of Goals:

  • For each relevant goal in the NDIS plan, include the goal as stated in the NDIS plan in the top box of each table.

  • In the left most cell of the table, write the occupational therapy goal(s) related to that NDIS goal.

  • In the next cell, comment on the client’s current performance. This should include:

    • What they could do before you began working on the goal

    • What they can do now

    • What therapy strategies you used to achieve this progress

    • What future therapy will look like for this goal

• • In the last cell in the row, comment on the goal status:

    • Achieved

    • Ongoing

    • Not Yet Addressed

Additional Evidence (if appliable)

• Attached Relevant Documents

  • List the relevant assessments, reports, or therapy plans with their dates in this table. Ensure that any items listed here are either included as an appendix at the end of the EOP report, or sent in the same email that the EOP report is sent to the NDIS.

Additional Information

• Changes and Support:

  • Comment on any changes in circumstances (not included in the main change of circumstance section above), new priorities, or barriers to therapy

  • Describe how support was provided and any success achieved

  • Please note: you may delete this section if the information was covered in previous sections

Future Interventions and Goals

• Future Goals

  • Identify new goals and interventions based on discussions with the client and their parent/guardian (these may also be found in updated assessment reports

• Future Interventions

  • Primarily using the list provided, detail specific interventions and assessments planned to address these goals.

Summary & Recommendations

• Summary and Progress:

  • This section is primarily written for you, but ensure you read through the paragraphs for relevancy to your client

  • You may choose to add more information, such as a recap of goals, achievements and ongoing needs.

  • Recommend continued therapy and other supports as appropriate for the client

  • Justify the need for additional funding and services based on the client’s current and future needs.

• Funding Recommendations:

  • Provide detailed breakdowns of recommend funding for therapy services, travel, and non-face-to-face provisions

    • You will notice that the first table has many rows. Please delete the rows not relevant (e.g. if your client is fortnightly and that is what you are recommending for the next plan, delete the row recommending weekly therapy)

    • Make sure that after deleting and adjusting rows, you recalculate the total at the bottom right of table 1.

  • Include additional recommendations for supports such as speech pathology, psychology, and support coordination.

    • For services already being accessed, refer the reader of the EOP report to those services recommendations in their own report

    • For new services, provide a short overview, with reference to comments made in your report, to justify why that service is required.

Signature and Submission

• Sign the Report:

  • Ensure the report is signed and dated

• Submit the Report:

  • Save the final report as a PDF in the client’s NDIS folder (not their OT folder) with the naming convention:

    • D.L – NDIS EOP Report - OT - MM.YYYY

  • Send the report to your direct supervisor for editing if required/wanted

  • Send the finalised report to the parent/guardian for proofing/approval

  • Enter the time spent on writing the report in the ‘Report Tracking’ Spreadsheet

  • Send the email to the NDIS. This can be done by either:

    • Locating the contact email on the client’s NDIS plan

    • Emailing the report to enquiries@ndis.gov.au if you do not have access to a recent NDIS plan

      • When emailing either of the above, ensure that the email includes the client’s name as it is written on their NDIS plan, their D.O.B and their NDIS Number.

      • Also remember to attach the EOP report and any additional reports mentioned in the EOP report.

The Ages and Stages Questionnaire, 3rd Edition (ASQ-3) and the Ages and Stages Questionnaire: Social-Emotional, 2nd Edition (ASQ:SE2) are parent/caregiver-report tools used to screen developmental and social-emotional milestones in young children. These assessments help identify areas of strength and potential developmental delays.

Time:

• As the ASQ forms are completed by the parent themselves, there is little-to-no time accounted for administration. Sometimes parents may have questions, however, the forms are typically answered during a normal session, so no additional time needs to be billed.

• The scoring, analysis and report writing for an ASQ form is typically 30-minutes per form, meaning if just an ASQ-3 or ASQ:SE-2 is completed, then the total time is 30 minutes, however, if both forms are completed and have a report written, it will take 60 minutes.

• Time total: 30-60 minutes

ASQ-3 Instructions

Purpose: The ASQ-3 evaluates five key developmental areas:

1. Communication

2. Gross Motor

3. Fine Motor

4. Problem Solving

5. Personal-Social

Administration:

• Who: Completed by the child’s parent or caregiver.

• How: Administered as a questionnaire to be filled out by the parent or caregiver.

Steps:

1. Preparation:

   • Familiarise yourself with the ASQ-3 questionnaire.

   • Ensure you understand the developmental milestones and the types of questions asked.

2. Administration:

   • Provide the ASQ-3 questionnaire to the parent or caregiver.

   • Explain that they should answer each item based on their child’s typical behavior.

   • Remind them to select the most accurate response: Yes, Sometimes, or Not Yet.

3. Scoring:

   • Review the completed questionnaire to ensure all sections are filled out.

   • Score each item according to the ASQ-3 scoring guide.

4. Interpretation:

   • Compare the total scores for each area to the cutoff scores provided in the ASQ-3 manual.

   • Determine if the child’s development is Above the cut-off, Close to the cut-off, or Below the cut-off.

5. Report Writing:

   • Use the provided ASQ-3 report template to compile the results and interpret the findings.

ASQ:SE2 Instructions

Purpose: The ASQ:SE2 assesses social-emotional development across seven behavioural areas, however, it should be noted that the final score is a total of the seven areas combined:

1. Autonomy

2. Compliance

3. Adaptive Functioning

4. Self-Regulation

5. Affect

6. Interaction

7. Social Communication

Administration:

• Who: Completed by the child’s parent or caregiver.

• How: Administered as a questionnaire to be filled out by the parent or caregiver.

Steps:

1. Preparation:

   • Familiarise yourself with the ASQ:SE2

questionnaire.

1. • Understand the behavioural areas and types of questions asked.

2. Administration:

   • Provide the ASQ:SE2 questionnaire to the parent or caregiver.

   • Explain that they should answer each item based on their child’s typical behaviour.

   • Responses are typically rated on a scale indicating how often the behaviour occurs.

3. Scoring:

   • Review the completed questionnaire to ensure all items are answered.

   • Score each item according to the ASQ:SE2 scoring guide.

4. Interpretation:

   • Compare the total scores to the cutoff scores provided in the ASQ:SE2 manual.

   • Determine if the child’s social-emotional development is Below the cut-off, Close to the cut-off, or Above the cut-off.

5. Report Writing:

   • Use the provided ASQ:SE2 report template to compile results and interpret findings.

Important Notes:

• The ASQ forms are broken down into months/days of age to ensure accurate peer analysis. Make sure you check that the age of the child (google ‘Pearson age calculator’ if needed to check exact biological age) is aligned with the age listed at the top-right of the ASQ form.

• Repeat administration with updated age forms every 6-12 months for NDIS reporting purposes.

• The ASQ assessments can be used as screening tools without reports if needed to support goal development or baseline data.

Writing the Report

• The ASQ-3 and ASQ:SE2 templates can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X – ASQ-3 Report - 2024.docx" and “X.X – ASQ SE-2 Report - 2024.docx”

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

• Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

Word Doc Template:

1. If you are unable to make edits to the document, ensure that at the top-right of the document, it says 'Editing' and not 'Reviewing'

2. Enter all client-specific background information

3. To replace terms:

   • select CTRL+H on your keyboard

   • Type in the word you want to change in the first field box

   • Type in the word you want it replaced with in the second field box

   • Click 'More'

   • Tick 'Case sensitive'

   • Click 'Replace all'

     • E.g. Change [CLIENT] to John; [his/her] to his etc.

     • NB: Make sure to include the [square brackets] in the first field box

4. Anything in red font in the template needs to be altered to be client-specific

5. Table 1: Use the scoring information from the last page of the ASQ form to enter the data into table 1. For the ASQ:SE-2, use the answers to each question to list strengths and challenges in dot point form, as well as any additional concerns listed by the parent.

6. ASQ3 Interpretation: Using the scores and answers for each question, write a paragraph on what the child has ‘mastered’ and which areas are still developing. Ensure you add observations and additional information from your sessions and things that have been reported to you.

7. ASQ3 Strengths and weaknesses: Use the answers to each question to list strengths and challenges in dot point form, as well as any additional concerns listed by the parent.

8. Recommendations: List any recommendations based on the strengths and challenges for the child. This may include ongoing therapy, new therapy goals, referrals to other professionals, strategies to trial at home.

9. Sign the report when finished

10. Send the report to your direct supervisor for editing if required/wanted

11. Save the report as a PDF with the following naming convention:

    • D.L – ASQ3 and ASQ SE-2 Report - 07.2024

12. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

The Print Tool is an assessment designed to evaluate a child's handwriting abilities, focusing on several key skills including memory, orientation, placement, size, start, sequence, and spacing. This assessment helps identify specific areas where a child may need support to improve their handwriting.

Time:

• The Print Tool can typically be administered (and sometimes scored) within one standard therapy session.

• The scoring, analysis and report writing for The Print Tool is typically 30-60 minutes, depending on depth of analysis and extent of handwriting challenges.

• NB: The report is optional and as such, this assessment can be completed without additional charge beyond a typical session.

• Time total: 30-60 minutes

The Print Tool Instructions

Purpose: The Print Tool assesses handwriting skills in the following areas:

• Memory: Remembering and writing dictated letters and numbers.

• Orientation: Correct direction of letters and numbers.

• Placement: Positioning letters and numbers on the baseline.

• Size: Size of letters and numbers.

• Start: Starting points for each letter or number.

• Sequence: Correct order and stroke direction.

• Spacing: Space between words in sentences.

Administration:

• Who: Administered directly with the child.

• How: The child will complete various writing tasks while you observe and score their performance.

Steps:

1. Preparation:

   • Familiarise yourself with The Print Tool’s guidelines and scoring criteria.

   • Prepare all necessary materials (e.g., writing paper, pencils, and any aids like slant boards if needed).

2. Administration:

   • Explain the tasks to the child in a clear, simple manner.

   • Provide the child with examples of what they are expected to do for each task.

   • Observe the child as they complete the tasks and take note of their performance in each area.

3. Scoring:

   • Use the scoring guide provided in The Print Tool manual to evaluate each handwriting skill.

   • Record the child’s performance in the areas of memory, orientation, placement, size, start, sequence, and spacing.

4. Assessment Results:

   • Compare the child’s scores to expected performance for their grade level.

   • Identify areas where the child’s performance falls below, meets, or exceeds the expected percentile.

5. Writing the Report:

   • Use the provided report template to compile and interpret the results.

Writing the Report

• The Print Tool template can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X – Print Tool Assessment Report - 2024.docx"

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

• Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

Word Doc Template:

1. If you are unable to make edits to the document, ensure that at the top-right of the document, it says 'Editing' and not 'Reviewing'

2. Enter all client-specific background information

3. To replace terms:

   • select CTRL+H on your keyboard

   • Type in the word you want to change in the first field box

   • Type in the word you want it replaced with in the second field box

   • Click 'More'

   • Tick 'Case sensitive'

   • Click 'Replace all'

     • E.g. Change [CLIENT] to John; [his/her] to his etc.

     • NB: Make sure to include the [square brackets] in the first field box

4. Anything in red font in the template needs to be altered to be client-specific

5. Assessment Results: Use the results from the scored assessment to fill in the percentages in tables 1 and 2.

6. Analyse the results further in the Summary section of the report, noting down letters and numbers that appear to be a challenge, or the percentages for each of capitals, lowercase and numbers.

7. Recommendations: Ensure that you read through the listed recommendation paragraphs and make sure that they are relevant and unique to your client.

8. Sign the report when finished

9. Send the report to your direct supervisor for editing if required/wanted

10. Save the report as a PDF with the following naming convention:

    • D.L – Print Tool Report - 07.2024

11. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'

The Peabody Developmental Motor Scales 2 (PDMS-2) is a standardized assessment tool used to evaluate motor skills in children from birth to five years old. This assessment measures both gross and fine motor skills and provides insights into how these skills impact daily functional tasks.

Time:

• The PDMS can be administered in three different ways:

• 1. As a questionnaire completed with the parent,

  2. As a standardised assessment administer with the child, or

  3. As a combination of both of the above.

• The three methods of administration have different times (NB: This will often be done in place of or during a typical therapy session.

  1. No administration time as the questionnaire is completed individually by the parent or with the therapist in place a typical session. The questionnaire may take up to two sessions (2 hours)

  2. To administer the assessment as intended with the child, depending on the child, is likely to take up to 3 hours.

  3. As a combination, where the parent completes what they can as a questionnaire and you complete the rest with the child will probably take one hour (not including the time spent by the parent)

• The scoring, analysis and report writing for the PDMS is typically 1-2 hours, depending on depth of analysis and extent of challenges.

• Time total: 2-5 hours

Important Notes:

·         Reflexes can only be assessed on a child who is 12 months old or less.

PDMS-2 Instructions

Purpose: The PDMS-2 assesses:

• Gross Motor Composite: Includes Reflexes, Stationary, Locomotion, and Object Manipulation.

• Fine Motor Composite: Includes Grasping and Visual Motor Integration.

• Total Motor Composite: Combines all sub-tests.

Administration:

• Who: Administered with the child by the occupational therapist.

• How: The child completes various motor tasks, while you observe and score their performance.

Steps:

1. Preparation:

   • Review the PDMS-2 manual to understand scoring and administration procedures.

   • Gather all necessary materials (e.g., balls, blocks, and other assessment tools).

2. Administration:

   • Explain each task clearly to the child, ensuring they understand what is required.

   • Observe the child during the tasks, noting their performance in each motor area.

   • Administer each sub-test according to the PDMS-2 guidelines, adjusting for the child's age and abilities.

3. Scoring:

   • Use the PDMS-2 manual to score each sub-test.

   • Record scores for each sub-test and composite score, noting the child's performance in percentile ranks.

4. Assessment Results:

   • Enter the child’s scores into the provided report template.

   • Create tables and graphs to visualize the child's performance compared to peers.

5. Writing the Report:

   • Complete the report template with detailed results and observations based on the child’s performance.

Writing the Report

• The PDMS Report template can be found on the OneDrive at: "C:\Users\joyfu\OneDrive - Joyful Journey Occupational Therapy\JJOT\Occupational Therapy\OT Template\Assessment Reports\X.X – PDMS Report - 2024.docx"

  • NB: Do not write in this template. Save a copy in the client's folder before writing in the document.

• Additionally, the template is available to complete as a Halaxy note if preferred. 

  • NB: terms in [square brackets] on Halaxy will automatically fill-in when you 'publish' the report.

Word Doc Template:

1. If you are unable to make edits to the document, ensure that at the top-right of the document, it says 'Editing' and not 'Reviewing'

2. Enter all client-specific background information

3. To replace terms:

   • select CTRL+H on your keyboard

   • Type in the word you want to change in the first field box

   • Type in the word you want it replaced with in the second field box

   • Click 'More'

   • Tick 'Case sensitive'

   • Click 'Replace all'

     • E.g. Change [CLIENT] to John; [his/her] to his etc.

     • NB: Make sure to include the [square brackets] in the first field box

4. Anything in red font in the template needs to be altered to be client-specific

5. Use the results on the PDMS booklet to fill in Table 1 and 2, and Graph 1 and 2.

6. Assessment Results: Use the results from the scored assessment to fill in the percentages in tables 1 and 2.

7. Analyse the results further in the Interpretation section of the report, noting down the descriptive term (Far Below Average, Below Average, Average, Above Average, Well Above Average) and the percentile rank.

8.      Recommendations: The PDMS assessment comes with a PDMS-2 Motor Activities Program which can be used to list recommended activities.

9. Sign the report when finished

10. Send the report to your direct supervisor for editing if required/wanted

11. Save the report as a PDF with the following naming convention:

    • D.L – PDMS Report - 07.2024

12. Email the report to the parent and enter the time taken to score and write the report in you 'Report Tracking Spreadsheet'