THERAPEUTIC RECREATION
THERAPEUTIC RECREATION RESIDENT ASSESSMENT
__Initial __Readmission __Annual __Change of Status
-----------------------
DOB: _____ Primary Language___________
Significant Other: _____________________________________
Expressed Needs:
Resident Appears:
__responsive __verbal __non-verbal
__alert __oriented __confused
__withdrawn __lethargic __painful
__agitated __anxious
Other:________________________________
Stated Recreation Interests:
__Art __Music
__Ceramics __Plants
__Crafts __Reading
__Creative Writing __Socializing
__Crossword Puzzles __Sports
__Games __TV/Video
Other: _____________________________
Recreation Therapy Orientation to:
__Resident __Family
Resources Provided:
__TR Calendar
__Voter Registration
__TR Building Tour
__Services & Supports of TR Staff
Previous Leisure Interests: ____________________________________
____________________________________
Present Leisure Interests:
_____________________________________ _____________________________________
Resident Statement:
_____________________________________
_____________________________________
Presenting Problem(s): Resident:
__is independent and attends/is interested in programs
__is restricted to bed due to medical reason
__ but remains fully responsive
__ and is unable to express needs
__refuses to attend group programs
__attends programs but has difficulty being active
__seen by frequent dosing, difficulty communicating
__due to physical limitation(s)
__has difficulty transporting self to programs
__has difficulty remembering schedule for programs
__experiences increased confusion and memory loss
__and frequently wanders
__and has difficulty focusing on tasks
__ is new to facility and needs to adjust to new environment
Other:_______________________________________________________________________________________________________
Goal(s):
Time frame: __30 days __60 days __90 days __ ________
Resident will:
__ attend at least 3 programs weekly.
__ attend at least 1 group activity per week by next evaluation
__ choose at least 2 recreational activities weekly
__ accept 1:1 visits by RT for at least 15 mn. 2x weekly
__and initiate and respond to conversation at least 2x per visit __ actively accept or refuse to attend group program daily
__ remain in program for at least 10 mn. at a time 2x daily
__ initiate/respond to interaction with peers at least 2x per group
__ respond to staff as appropriate at least 2x per program
__ respond to auditory and tactile stimulation seen by __________
__ complete at least 2 tasks per program
__ complete at least 2 memory related tasks per program
__ complete at least 2 reality orienting tasks per program
__ ask for assistance when needed
__ express recreational needs to RT as appropriate
__ Other:____________________________________________
Staff Intervention Plan:
__Provide TR services and schedule to resident & family
__Collaborate with interdisciplinary team
__Provide 1:1 visits
__Provide and encourage recreational activities
__Encourage and escort to programs
__Provide and encourage appropriate group tasks
__Other:_____________________________________________
_____________________________________________________
Recreation Therapist Date
................
................
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