RECTH 4320

Recreational Therapy Assessment of an Individual with a Physical Disability

Identifying Data
Name (use alias for confidentiality) Joe
Age 45
Gender Male
Date of Admission to Facility/Program 11/9/2021
Primary Diagnosis Tumor which led to Spinal cord injury on T5 which went from incomplete to
(The dx/s that caused the admission or referral of the client) complete.
Secondary Diagnoses Broken humerus which doesn’t allow for much left arm movement
(Other dx/s that are still active – the person is still experiencing – that are
not the primary reason for admission/referral of the client)
Past medical history None
(Other dx/s that the client had in the past that are no longer active)
Precautions Gets spams.
Diet N/a
Medications Tramadol.
Education (highest level achieved) Bachelors at Oklahoma state
City & state of residence; characteristics of home & living situation Lives in
Employment status & occupation Professional athlete and volunteers for the VA
Social roles/social support Family is very supportive. Fiancé and kids
Religious and cultural values N/a
Life habits Sports, basketball and skiing.
Client goals (What does he/she hope to accomplish?) 2022 Paralympics in Beijing
Reasons for admission To increase physical ability after T5 spinal cord injury. Pt. wants to increase
(What is the main reason the person is at your particular facility or physical ability to reach 2022 Paralympics
participating in this program; e.g., respite, decreased independence in
functioning, rehabilitation)
Reason for referral to RT Pt. wants to partake in Adaptive Basketball and Skiing. Pt. plans on making it
(Reason for referral will vary by setting/program, please be sure to talk with to 2022 Beijing Paralympics
your supervisor to find out the specific reason for RT treatment/services;
what is hoped to be accomplished through Rec Therapy services at this
facility/program?)

1

Using the facility RT assessment tool, secondary sources (e.g. chart, family, staff, etc.), and/or a standardized RT assessment tool, conduct a functional skills
assessment of your client and list your assessment findings in the chart below. This section should be reflective of skills of a 2 nd year RT Student.
Assessment Methods
Instructions: What assessment
tool/source/method did you utilize
(e.g., medical chart review,
observation within activity,
discussion with a specific team
member/team/physician, client or
family interview, standardized
assessment tool, etc)? What
specifically did you look for/do?
Why did you do this (how does it
relate to the client’s diagnoses)?
The assessment used for this was a
client interview. During the
interview certain question to get the
identifying data and while asking
this data it created conversation
where the information is grabbed
from.
Functional Skills Assessment
Assessment Domains
Do not write anything in this
column.
Note: While all domains are
important, since this course
focuses on clients with physical
disabilities, be certain you have
comprehensively assessed physical
functioning.
Physical functioning
Cognitive functioning
Speech/language/communication
functioning
Assessment Findings
Instructions: Report measureable
assessment findings. After each
finding, indicate the source where you
obtained the information using the
below codes: (e.g. Hard of Hearing –
O, MC; Loneliness – SR; R Hemiparesis
– O, MC, P)
O Observation
MC Medical Chart
T Standardized Assessment Tool
(administered by you)
P Pt hx (anything told you to by
the family, other team
members, etc.)
SR Self-Report (items told you to
you by the client)
O| Functioning seems to be well with
pt. preparing for Paralympics and
having played professional wheelchair
basketball.
O| Pt. is engaging in conversation
with no problems.
O| Pt engages in conversation well
and comprehends everything being
Interpretation of Findings
Instructions: After reviewing your
assessment findings, what
preliminary conclusions can you
draw from the assessment data?
How do you foresee the client’s
strengths/weaknesses impacting
his/her recreation/leisure
engagement, health, and quality of
life (RT scope of practice)?
*Pay careful attention to when it is
appropriate to use absolute (e.g.,
will) verses flexible (e.g., could,
might, may) terms.
With pt. having such a positive
attitude and willingness to get
involved with leisure. This could help
pt. participate in other activities that
could help better improve their
physical functioning.
Pt. engaging in normal conversation
could facilitate session and
discussions done in them.
With pt. speaking and understanding
everything said to them the
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 told.
Psychological/emotional SR| emotional function is well, pt
functioning states that they did suffer from
depression at one point but the
opportunities and family he had
helped them get to a better state
Sensory functioning SR| pt. states they do not have any
sensory functioning problems
Social functioning SR| pt. talks about friends they have
and all the people that they help
through mentoring.
Self-care functioning SR| Pt. states they are independent in
all of their self-care functioning and
transfers unless architectural barriers
are found.
Play/leisure/recreation/ O| Pt. participates in many sports and
community functioning community activities with friends and
family.
communication needed will flow
smoothly through the RT treatment
Pt. being in a good emotional health
will help them stay focused on their
goal and not give up on it.
Pt. having no sensory problems will
allow them to partake in more
activities without the extra worry of
hurting something and not being
able to feel it.
With pt. having a strong social
functioning he can participate in
group session and help get the
conversation started with pt. who
are
Pt. being able to do all their self-care
functions indicates their
independency and RT should make
sure to value and respect that.
Pt. enjoys many sports, leisure and
recreation which show how
important they are in their life and
their openness to try new activities.
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 Leisure Lifestyle Review
Identify leisure interests and activity patterns for your client. Each activity should be coded as a current, past and/or future interest.
Add additional rows if needed.
Current (C), Activity How often With who Where Other Notations (possible information to include):
Past (P), & 1) Provide other specific notations about the activity that does
Future (F) not fit in the previous columns.
interests 2) Explain the barriers (or foreseeable barriers/challenges) to
performing the activity.
*List in this 3) Explain the facilitators that could enhance the client’s ability
order to participate in the activity.
4) Explain any reasons to be concerned about the activity (e.g.,
unhealthy, could cause harm to self or others).
5) Explain reasons (if known) about why past activities are not
being done any more.
6) Explain motivation for participating in this activity.
(C) Skiing varies unknown NAC Patient is training for Paralympics 2022. Some of the barriers
they face are some like falling the lift and breaking their
humerus. Facilitator could help improve safety for participant to
ensure they do not get injured. The reason to be concerned is
that this is a risky activity and could cause serious injury if not
done properly and safely. Motivation for this activity is for
leisure and sense of proudness towards family.
(C) Basketball Every With best Salt Lake Barriers that pt. could face is finding enough people to play with
Thursday friend county them and also having all the equipment as the wheelchairs for it
adaptive can be expensive and having played at such a high level it would
be preferable for them to play with people their same level so
that they can reach flow and not get easily bored. Some
precautions that should be taken are ensuring that the pt. is not
putting too much pressure on their right shoulder or reinjuring
their left humerus. Pt. participates in this activity as they enjoy it.
(P) Soccer Used to do friends N/a Pt. partook in this activity primarily before his injury and they
It every day don’t state doing it more after the spinal cord injury. They could
after school still participate in wheelchair soccer. Pt. does state that they
enjoy watching it and watching their nieces and nephews play.

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 Major Concerns
Given your assessment findings, what are three priorities for
treatment/service? List one overarching area in each box.
Make sure at least one of these relates to physical functioning.
Increase physical strength
Increase social interactions
Increase coping skills
https://www.frontiersin.org/articles/10.3389/fphys.2018.01924/full
Why is this a priority? Explain how it relates to participation in healthy
leisure activities (especially those that are meaningful to the client), as
well as how it relates to health promotion, rehabilitation, and/or quality
of life.
The reason this is a priority is because pt. is trying to participates in
sports professionally and states some physical difficulties. By focusing on
this pt. will be in best physical state to rehabilitate and participate in the
leisure they enjoy.
Increasing social interaction is a priority as it seems like that is one of the
pt. interest and they enjoy meeting new people an helping them. This
would help in his health promotion and self-esteem
This is a priority as patient mentions how he wants to make family proud
as they used to when they played soccer before and even with family
supporting they still feel like they are not accomplishing this at times.