Documentation

Presenting assessment findings, outlining clinical analysis and treatment plans.

Clinical documentation can be tailored to meet your requirements. Documents include short summary reports for individuals who are self-funding their rehabilitation to comprehensive reports and summaries for litigation or insurance purposes.

Assessment Reports

The Fundamental Activities of Daily Living Report and Performance and Participation Report assessment and review process is unique to Krysalis.

The assessment and review process was devised by a working party of highly skilled clinicians. The tools have been devised from current evidence-based practice, and are designed to ensure that the individual, at all times, remains central to the rehabilitation process whilst at the same time providing a platform for the Occupational Therapist to present their clinical analysis and objectives.

  • I was knocked off my bicycle by a car and suffered a head injury. I could never have imagined the consequences of this and the impact that it would go on to have on my own and my family's lives.

    Brain injury survivor

  • I feel there is a veil over my face; a haze, a fog, something that is stopping me. The world is moving faster round me.

    Brain injury survivor

  • I haven’t run since this happened…… and with my reduced balance, I have visions of me falling over and ending up back where I started!

    Brain injury survivor

  • I feel a bit like a broken bloke.

    Brain injury survivor

  • Mathilda is my dog and I feel very sad when she sits by me and puts her head on my lap. I can’t take her for walks.

    Stroke survivor

Fundamental Activities of Daily Living Report

A Fundamental Activities of Daily Living Report is completed after the first meeting with the individual.  

The report will help you to understand how an individual lives their life and spends their time. We will consider:

  • what has changed
  • what has stayed the same
  • what has caused the difficulties
  • what influences them.

Our report provides a baseline of abilities and findings from the initial assessment visit before a period of rehabilitation. It reflects the activities an individual completes or wishes to complete on a daily basis.

This includes activities, such as:

  • what we have to do, for example, roles and responsibilities for work or family
  • activities we want to do, such as activities we enjoy for fun, leisure, recreation and play
  • activities we should do because it is good for us. This includes activities that require self-discipline and willpower, for example exercise, as well as activities such as grooming, eating, washing, cleaning our teeth and maintaining our health and wellbeing.

Combined with the assessment analysis, an objective standardised outcome measure is used by the Occupational Therapist to obtain a baseline of an individual’s functional ability with a variety of activities specific to the individual.

Our routine day-to-day activities are often ‘over learned’ and, therefore, performed efficiently, however disruption, such as within brain injury, can increase the demand required to fulfil them.

Drew Leder

Performance and Participation Report

As the process of assessment and intervention continues beyond the Fundamental Activities of Daily Living Assessment, we gain a richer understanding of the individual’s abilities and their engagement with activities.

The Performance and Participation Report template includes the Occupational Therapist's opinion on an individual’s functional abilities, incorporating individual performance skills and, specifically, how activities are motivated, organised and performed. If appropriate, a summary of any functional assessments that have been completed are included to add depth to the report. 

We work holistically and think about all the factors, in either a positive or negative way, that influence an individual’s ability to live their life.

The following factors guide the rehabilitation programme and will be considered by the Occupational Therapist.

Motivation
We all have our own unique personal values and interests that influence our day-to-day lives. These factors are important as they determine how an individual views themselves in relation to their disability, the choices they make and the activities they undertake, or chose not to undertake, on a day-to-day basis.
Coffee
Our lives are guided by routines and habits that are essential for everyday living. For all of us, routines and habits help us to develop skills and guide our decision-making and life choices. Our habits and routines often feed into the roles we have and, therefore, the perception we have of ourselves.
Environment
We are all influenced by our environment. This includes: our physical environment; the space around us, whether this be our home, local community and workplace; and, our social environment, which includes the influence of others in our life.

It is recommended that the Performance and Participation Report is completed at week 12 and then every 12 weeks thereafter to review progress and monitor change. Where required, equipment recommendations will be included.

We recognise that the Fundamental Activities of Daily Living Assessment and the Performance and Participation Report may not be suitable or required for all referrals; for example, individual assessments for seating needs or upper limb rehabilitation programmes would be best met by our Short Report. The type of report required will be discussed at the initial enquiry stage.

I was knocked off my bicycle by a car and suffered a head injury. I could never have imagined the consequences of this and the impact that it would go on to have on my own and my family's lives.

Brain injury survivor

Supporting Documentation

Functional Assessments

Completing functional assessments are a core skill of an Occupational Therapist where we can observe an individual completing an activity; for example, cleaning teeth or preparing a meal.

The Functional Assessment reflects the key components of a client’s performance and participation within a chosen activity, and includes a task analysis and assessment of physical, cognitive, executive function skills, fatigue, and behaviour relevant to the diagnosis.

Rehabilitation plans, care plans and risk assessments

Care plans and risk assessments are documents that are produced by an Occupational Therapist to inform individuals, family members and support teams in ways of maximising independence. The documents may outline specific guidance relating to a routine or activity.

Specialist risk assessments can be produced to facilitate an activity or to manage risk associated with complex behaviour that could impact on the safety and wellbeing of the individual or their support team.

Goals

We support individuals with their rehabilitation and are not guided by our own objectives or agenda.

Our goals are personalised and designed to track progress. They give a baseline or a starting point from where you can see growth and change.

“A goal is a dream with a deadline.”
Napoleon Hill

“Whatever you can do or dream you can, begin it; Boldness has genius, power, and magic in it.”
Johann Wolfgang von Goethe

Session summaries

A summary of the work undertaken following the visit to a client in a summary. The document will reflect, if applicable, the goals being worked on in that session and any observations and analysis from the Occupational Therapist. If a formal summary is not required a monthly activity log will be provided.

A unique journey

Penny’s husband George sustained a brain injury after a fall in his bathroom.

She talks openly about George before the accident, the impact of his injuries and the challenges they have faced together.

Meet Penny

What others say about us

  • I am always so impressed by the therapist’s commitment to and ongoing understanding of Claire and her situation. I am sure the rest of the family will share my thoughts so please pass on our heartfelt thanks to the therapy team when you next see them. Sister of brain injury survivor
  • I just wanted to drop you a line to say, whenever I call the office, Claire, in particular, is always very charming and efficient. She is a good representative of your company and has a nice phone manner and a good approach to customer service. So, thank you Claire. Mother of brain injury survivor
  • The following will never be enough to illustrate Paul’s journey but we are eternally grateful to the NHS, IM, ILS, Krysalis and the whole infrastructure that has been created for Paul. Yes, Paul is focused, determined and driven but the whole team have created a rehabilitation environment that has changed our life and Pauls future, they have made the thought of life and rehabilitation, turn from the impossible to the possible. Brother of brain injured survivor
  • The thought of having the family undertake this journey alone seems impossible and we will be always grateful. We all recognise that James is still on the rehabilitation journey, but there is no stopping him. He has just walked to Mum’s & Dad’s on his own (phone first to say he’s on his way)... what a way to celebrate the 2-year journey.Brother of brain injured survivor
  • I highly recommend Krysalis Consultancy OT services. Anna has been our life line since she came on board to help my husband following his brain injury. He has improved greatly thanks to Anna’s input in assisting him to become independent, teaching him step by step the simple things which we all take for granted. Anna is there for us 100%, teaching us both strategies to enable us to achieve better results.Wife of brain injured survivor
  • Just a short note to thank you very much for your hard work and persistence over the last few months, your guidance has undoubtedly helped and taken the pressure off me (I have benefited from the sessions greatly). I am really encouraged by the last few weeks and optimistic that if Peter keeps working at it he will continue to make good progress.Brother of brain injured survivor

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