Vocational Evaluation

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Staff-Patient Ratios One occupational therapist can treat eight to fifteen patients per dey The number of patients depends upon types of disabilities and the severity of the cases.

Where highly individual treatments are required, the daily load will decrease. Also, if the therapist is relieved of administrative responsibilities and assisted by nonprofessional persons, the daily load will increase

For orthopedic patients, special equipment must frequently be devrsed under close supervision of the occupational therapist.

There ere many variables applicable to staffpatient ratios.

Organization of Space The activity area may be so planned that each activity has a separate unit, or it may be planned to separate quiet from noisy and dusty from clean activity. The unit system facilitates assignment of special instructors to special activities and is also a more orderly arrangement of the space- However, this method increases the number of staff, makes supervision more difficult, and can be considered only in larger departments

The activities of daily living (ADL) area, which is used to teach the palient how to live self-sufficiently in his home environment, should be closely retated to the main occupational therapy treatment room.

As the occupational therapist works closely with the social adjustment staff and the vocational counselors, his office should be near their areas,

Activities of Daily Living The activities which are indicated include most situations found in the home (sec Fig. 101.

Some training, particularly bathroom and

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bedroom activities. will require cooperation with physical therapists- Consequently, the ADL area should be easily accessible from the physical therapy department.

A gadget beard containing numerous items of hardware, light switches, faucets, and other items frequently used should be included. The board should be adjustable in height.

The bathroom should be arranged to accommodate wheelchair patients (see '"Inpatients").

The kitchen plan may include, in addiiion to the type illustrated for wheelchair use. standard counter and cabinet arrangements to test the patient s ability to cope with "normal'' situations. Counters of adjustable height may be used to advantage in training patients,

A front loading washer and dryer, as illustrated, is desirable for wheelchair patients. Controla at the front of the range are recommended. However, the purpose of this training is to show the patient how he may use, if possible, appliances thai are standard in his community.

A standard clothes closet is recommended as a part of the training in dressing.

A broom closel, vacuum cleaner, and adjustable ironing board should also be included.

Table space should be provided for training in eating and for use as a writing surface.

A rug can also be used to test the palient's ability to cope with that type of floor covering.

Speech and Hearing

The speech and hearing unit serves those with disabilities of deafness, stuttering, or delayed speech and voice disorders which may result from various baste abnormalities, diseases, or injuries.

A wide variety of programs is possible. Some provide for treatment of postoperative disorders resulting from tonsillectomies and ear operations, cerebral palsy, meningitis, cleft palate, hemiplegia, vocal cord anomalies.

Services may range from testing and treating of all conditions to emphasis on disorders associated with certain specific disabilities-

The center may include speech therapy only or audiological testing as well.

The program may serve adults or children, or both.

The center may Include a teaching and research program in speech and hearing.

Staff-Patient Ratios Although ratios vary widely with different patients, an approximation of staff-patient ratios is as follows:

1. For eudiometric screening: one audio-metric technician may screen one patient every five to eight minutes.

2. For audiometric testing: the audiologist may test four to eight patients per day during the initial screening process. For a complete test for hearing aid evaluation, three hours is needed per patient, and the test is usually conducted in two visits.

3. For individual therapy: one therapist for six to ten patients per day (one half-hour to one-hour periods). The audiologist may also act as therapist.

4. For group therapy: five to eight persons per therapist; one therapist for twenty-four patients per day.

Organization of Space Patients' toilet facilities and coat racks should be accessible from the waiting room. It is recommended that the sound control room, test room, and audio-metric testing rooms be located on a subcorridor off the waiting room in order to reduce noise In a children's program, a play and e*-

Fig. 11

amination room near ihe test room ia recommended.

Audiometric Testing The audiometric testing room (or, in some cases, booths! is a facility for pure-tone threshold testing and short form hearing screening tests (see Fig. 11),

Space should be provided for the audiologist s desk with an audiometer and one patient's chair or wheel chair. Furniture should be arranged so that the audiologist may face the patient and operate the audiometer. Provide storage and shelving.

The room should be treated acoustically for an overall residual noise level of not more than 40 decibels as measured on the 4,C" scalenus involves the treetment of walls, ceilings, and floors. (See Fig. 12.)

Control Room and lest Room This facility is essential for an audiology program

It is preteroble to place these rooms off the subcorndor or hall, and to control the activity in surrounding rooms in order that extraneous noises be eliminated.

For a children's program it is highly desirable that, outside the test room, a play and examination room be provided to accustom the child to his environment and to make the transition to the test room as easy as possible This room should be equipped with children's furniture and toys-

Equipment for the control room will include a work surface for the audiometer, earphones and microphone, tape recorder, and tape and record storage, and may include other equipment such as a Bekesy audiometer. %,

If hearing aid evaluation is part of the program, provide storage space for hearing aids either in the test room or the control room.

The control room should be treated acoustically to achieve an overall residual noise level of not more than 40 decibels on the "C" scale, An observation window approximately 18 by 20 in. is required. For adequate control of sound transmission, three pieces of glass of different thicknesses and nonparallel in construction are recommended. One-way vision glass in the control room is optional.

Equipment for the test room includes a speaker, microphone, and headphone. Microphone and headphone jacks should be located near the patient's chair. Additional auxiliary wall- or ceiling-mounted speakers are sometimes provided, particularly for the testing of children. These speakers should be separately switched. All this equipment is wired to the audiometer. Additional spare jacks in both the control and the test room are recommended for other items of equipment. Conduits between the jacks should be installed in a manner that avoids sound transmission.

For complete diagnostic service, a galvanic skin response audiometer may be used in the test room. For diagnostic testing, delayed auditory feedback equipment may be used. For a children's program, children's furniture and toys should be part of the lest room.

The test rooms should be acoustically treated to achieve an overall residual noise level of not more than 30 decibels on the "C" scale- This requires carefully supervised construction of a 'floating room." In new construction the subfloor may be depressed to eliminate the high step or ramp at the entrance to the test room. If built on grade, the floating slab for the room may be placed on a sand bed.

To achieve this degree of acoustic control, it is essential that the floating room have adequate "mass" and thai all necessary precautions are taken to avoid the conduction of sound,

Proper air circulation is a frequent problem. Orthotic and/or Prosthetic Appliance Shop

Orthotic appliances are medically prescribed for the support of weakened parts of the body and to increase or control their function. Prosthetic appliances are medically prescribed artificial substitutes for a missing body part, Such devices are constructed by orthetists and prosthetists in cooperation with the physician, the physical therapist, and the occupational therapist, (See Fig. 13.)

The type of facility for orthotic and prosthetic services will vary widely with rehabilitation centers and ia dictated at times by the availability of commercial services.

Frequently, arrangements are made for a representative of a commercial firm to visit the center. For this purpose a fitting room is recommended as a minimum facility, although an office or treatment cubicle is sometimes used and minor adjustments and repairs to appliances are made in the occupational therapy department.

However, a small shop (as illustrated) within the center provides close liaison between the patient, the medical team, and the orthetist or prosthetist. In such a shop, small devices such as feeders and page turners may be fabricated and adjustments and repairs made to wheelchairs, braces, limbs, and crutches.

If a minimum facility is established, consideration should be given to its future expansion, not only in terms of space, but with respect to electrical services, ventilation, gas supply, etc.

speaker tape recorder ear phones microphone-

phonograph

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Fig. 12 Plan of typical audio testing area

The fabrication of major appliances requires much heavy and noisy equipment. Isolation of such a shop is essential to the control of noise and reduction of the fire hazard,

Location Within Building As the orthotic and/or prosthetic appliance shop will serve outpatients requiring minor adjustments or repairs to their devices, the unit should be easily accessible to entrances.

The unit should be located in a noisy zone, and, if possible, near the gymnasium, so that the patient may try out his prostheses or braces. The fitting room, however, may be made sufficiently large tor this purpose.

SOCIAL AOJUSTNieilT

Social adjustment requires psychietric and social services for the treatment of social and emotional problems.

Psychiatric Service: Frequently the psychiatrist is employed on a part-time basis and is primarily called upon to provide the following services:

1. Psychiatric screening lo diagnose emotional problems

2. Staff consultations on how these problems should be managed in relation to the patient's total rehabilitation program

3. In-service staff training for the purpose of developing greater understanding of the psychological factors in disability

Psychological Services include:

1. Psychological evaluation, accomplished by means of various psychological testing procedures and interviews which evaluate the patient's intelligence and personality

2. Interpretation of clinical findings to members of the staff

3. Counseling (therapy) on either an individual or a group basis, usually carried out with the psychiatrist and social service staff

4 In-service training of psychologists and participation in psychological research.

The minimum recommended psychological facilities would include a psychologist's counseling room and test room.

Social Services include the following:

1. Social study and evaluation, including the collection of relevant information from the patient, his family, and other agencies, ond the appraisal of such information with respect to the patient's rehabilitation potential

2. Social casework, where the social worker {madical social worker or psychiatric social worker) works with the patient to improve attitudes toward aelf-aupport and motivation toward treatment and work

3. Social group work, including the correction of abnormal living patterns by using planned group activities, recreational in nature but therapeutic in value, tt may include hobby activities, group discussions, and activities of an adult education nature.

Location Within Building The service« should be administered in a quiet area of the building.

As most incoming patients will receive some services in this area, it should be readily accessible from Ihe main entrance of the building.

If the program involves large numbers of children, the psychological therapy room for children should be in the children's treatment-training unit.

Organization of Space The flow pattern tor patients within this area will vary considerably. A typical pattern for the evaluation of a new patient would have the sequence of receptionist, waiting room, social worker (for caso history of patient), medical evaluation (for all incoming patients), psychological testing, and psychiatric screening The two latter services are not needed by all patients

Vocational counseling, and appraisal of the patient's employment potential in the vocational evaluation unit may also be included in the initial evaluation, Also for this purpose, audiometric screening and speech evaluation are oflen helpful.

Slaff-Patient Ratios As psychiatric screening and psychological therapy will vary widely with individual patients, no approximation of staffpatient ratios is possible.

For psychological testing a recommended average is two patients a day per psychologist for brief psychological evaluations. This includes the time required for interpretation and writing reports. Extensive psychological evaluation requires one work day per patient, Including time for preparation of the report. Other activities such as training, research, and therapy will detract from these averages. This does not provide for evaluation of vocational skills, aptitudes, and interests, which is a function of vocational services.

For social caseworkers, the number of cases per worker will vary with the number of intake studies and the number receiving continuing service- Where there is a balance between these two types of service, an individual caseworker may handle a caseload of from 25 to 35 patients.

Waiting Room If the program is of sufficient scope, provide a separate waiting area with a receptionist for the psychological-social unit. In smaller centers, this facility may be incorporated in the main waiting room for the center.

The receptionist schedules patient interviews with the psychological-social staffAccess to interview and test rooms by means of a subcorridor will provide privacy and reduce extraneous noise from the rest of the building.

Psychological Training and Research Programs For a training program, provide observation facilities in the children's play therapy and activity group rooms, such as observation cubicles with one-way vision glass or, preferably, television cameras with screens in a central viewing room. (See Fig. 15.)

Provide a separate office for each psychological trainee.

Research programs are of a wide variety. Some involve much equipment; others, no equipment. Provide a separate area for this facility

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