Buettner Assessment of Needs, Diagnoses and Interests
for Recreation Therapy in LTC
This assessment is designed to follow the MDS 3.0 and to help the practicing recreational therapist review all
relevant areas of function and design a RT Care Plan. The minutes and days of RT should be documented in
Section O. for eligible residents.
Step 1: Complete the Data Sheet by reviewing the resident medical record and by talking with members of the
interdisciplinary team. Data Sheet information provides the recreational therapist with a medical and social
overview of the resident and provides safety information. Please include the specific MDS information in the
last section.
Step 2. Complete the Mental Status Summary page. The information for this section of the assessment should
be taken from the MDS 3.0 Sections C and D. Summarize the findings at the bottom of the page.
Step 3. Complete the Leisure History and Interests interview by using the categories listed in the interview
guide. You should say “ I want to ask you about things you like to do during your free time. Are there any
creative outlets that you enjoy? If the resident is not able to name any you may list a couple from the list, or if
the resident is not able to answer ask a significant other about creative activities. Then clarify “do you want to
do that now?” or did you do that earlier in your life?” Then move down to entertainment, games, home,
nature/outdoors, physical, social/community, technology and new things to try using the categories as your
guide. Summarize and prioritize the types of things the resident enjoys at the bottom of the page. This
information should guide you in developing a motivating intervention that will lead to a lifestyle change.
Step 4. Complete the MDS Summary page by reviewing the major problem areas or concerns that impact on
RT interventions in Sections B, C, D, E., F, G, H, and J. Note Active Diseases from Section I and Skin
Condition from Section M. These areas may direct your objectives and methods for interventions.
Step 5. Complete Treatment Considerations page by circling all areas that apply to your resident. This page
provides details on function, preferences, and background to help the RT individualize interventions. Included
on this page are preferences from Section F and Other Considerations.
Step 6: Complete the Recreational Therapy Care Plan by listing Needs & Problems as well as Strengths.
Consider recreational interests as you plan. Design a goal and behavioral objective(s) as step to achieving the
goal. Obtain the MD or NP Order for recreational therapy. Review the plan with the resident and sign and date
the assessment.
Use the Flow Sheet to record progress during each session. Document your RT minutes and days of treatment in
Section O. of the MDS 3.0 even if you are providing co-treatment with another therapist.
© 2011 Buettner, Connolly & Richeson, 2011
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Buettner Assessment of Needs, Diagnoses and Interests
for Recreation Therapy in LTC
Section 1: Recreation Therapy Face Sheet
Name: ____________________________________________DOB_____________ Gender_____________
Room #/Unit: ____________ Admission Date: ____________ Rehab or Long Stay: ________________
Resident Information
Primary Language Spoken: ____________________ Secondary Language: ________________________
Family Contact: ____________________________________________ Phone:______________________
Past Occupation: _________________________________________ Military:
____________________
Spouse/Significant Other: ________________________________________________
Family Members/Close Friends: __________________________________________________________
Religious/Spirituality ____________ Ethnicity: ________
Education: ______
Marital Status:______
Special Considerations for Recreation Therapy
Fall Risk: ________ One-sided Weakness: ______________
Assist to Ambulate: __________
Recent Fracture/Surgeries: _______________________________Seizures: _______
Swallowing Difficulties: ___________
Diabetes: ____
Dietary Restrictions: __________
Food/Other Allergies:__________
Medications (Section N)
Antipsychotics
___
Hypnotics/sleep ___
Anti-anxiety ___
Antidepressant ____
Anticoagulant ___
Place an “X” by those that apply: Smokes tobacco ____ Wanders/Elopes _____ Pica ______
Sun Sensitive: _____ Assist In eating ____ Drinks alcohol ___ Fears Animals _____
Aggressive: ______ Possible danger to self or others ____
Check which MDS information was used:
MDS Admission Assessment ____ Quarterly ___ Significant change_____ Date: ____________
© 2011 Buettner, Connolly & Richeson, 2011
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Buettner Assessment of Needs, Diagnoses and Interests
for Recreation Therapy in LTC
Section 2: Mental Status Summary
Name: __________________________________________________________ Date: ________________
Directions: The information for this section of the assessment should be taken from the MDS 3.0 Sections C
and D. Examine Section C. Brief Interview for Mental Status of MDS 3.0.
C. 5 Cognition
Was the resident able to be interviewed? Yes or No
If Yes:
Short term memory score:
______/3
Temporal Orientation score:
______/6
Recall:
______/6
Summary Cognitive Score C5 ______/15
If No (Staff assessment findings):
Short Term memory _________________________________________________________
Long Term Memory _________________________________________________________
Memory/Recall
_________________________________________________________
Cognitive Skills for daily decision making _______________________________________
C. Delirium
C. 12
In the past 5 days did the resident code for any behaviors associated with delirium? Yes or No
C. 13 Is there Evidence of an acute change in mental status? Yes or No
D. Mood
Directions: Examine Section D. PHQ-9 for signs of depression. Total Severity score for Mood
______/27
Summary/findings for Mental Status
(Report cognitive functioning, possible delirium, and presence of depression symptoms)
Buettner Assessment of Needs, Diagnoses and Interests
for Recreation Therapists in LTC
© 2011 Buettner, Connolly & Richeson, 2011
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Buettner Assessment of Needs, Diagnoses and Interests
for Recreation Therapy in LTC
Section 3: Recreation/Leisure History and Interests
Interview the resident by using the categories listed in this section. You should say “I want to ask you about things you enjoy doing in
your free time or to stay active.” Then start with the first category and ask “are there any creative activities you enjoy?” You may give
some examples that are in the parentheses. If the resident mentions an activity, be sure to probe further to obtain specifics, such as fly
fishing, rather than just fishing. Finally, ask if there is anything new he/she would like to learn or to try through recreation therapy.
Creative: (Painting, crafts, woodworking, jewelry making, sewing, playing an instrument, etc)
Entertainment: (Music, television, watching sports, concerts, etc)
Games: (Board, puzzles, word, cards, computer, etc)
Home Activities: (Cooking, fixing things, tinkering, organizing, cleaning)
Nature/Outdoors: (Gardening, sitting outside, hiking, hunting, camping, fishing, bird watching, boating)
Physical Activities: (Walking, exercise, sports, biking, swimming, dancing, etc)
Social/Community: (Restaurants, travel, community organizations, clubs, volunteering, parties, etc)
Technology: (E-mail, internet, handheld games, smart phone, etc)
Well-Being: (Reading, Family, friends, pets, taking classes, education, church, meditation, relaxation, etc)
New things he/she would like to try:
Summary:
© 2011 Buettner, Connolly & Richeson, 2011
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Buettner Assessment of Needs, Diagnoses and Interests for
Recreation Therapy in LTC
Section 4: MDS Summary
Resident: ________________________________________ Date: _______________
Summary of Functioning Levels
Sensory (Section B) _______________________________________________________________________________
Cognitive (Section C) ______________________________________________________________________________
Psychosocial/Mood (Section D) ______________________________________________________________________
Behavioral (Section E) _____________________________________________________________________________
Personal Preferences (Section F) _____________________________________________________________________
Physical/Mobility (Section G) _______________________________________________________________________
Continence (Section H) ____________________________________________________________________________
Pain (Section J) __________________________________________________________________________________
Active Disease Diagnoses Section I MDS 3.0
Cancer: _______________________________________________________________________________________
Heart/Circulation: ______________________________________________________________________________
GI: __________________________________________________________________________________________
Genitourinary: _________________________________________________________________________________
Infections: ____________________________________________________________________________________
Metabolic: ____________________________________________________________________________________
Musculoskeletal: _______________________________________________________________________________
Neurological: __________________________________________________________________________________
Nutritional: ___________________________________________________________________________________
Psychiatric/Mood: ______________________________________________________________________________
Pulmonary: ___________________________________________________________________________________
Other: _______________________________________________________________________________________
Skin Section M MDS 3.0
Ulcer: ___________________________________________________________
Buettner Assessment of Needs, Diagnoses and Interests
Surgical wound; _____________________________________________________________
Cellulitis
for Recreation Therapists in LTC
__________________Burns__________________________________
Pressure reducing devices __________________________________________________
Buet
© 2011 Buettner, Connolly & Richeson, 2011
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Buettner Assessment of Needs, Diagnoses and Interests
for Recreation Therapy in LTC
Name: ________________________________________ Date: _______________
Section 5: Treatment Considerations
Directions: Circle all that apply
Behavioral Issues: Apathy Danger to self/others Physical aggression Physical non-aggression (rubbing, pacing)
Removes clothing
Refuses: Care, Activities, Medications
Verbal abusive to others
Verbally non-abusive
(complaining, repetitive)
Screaming
Wander/Elopes
Other: _______________________________
Communication: Aphasia: Global, Receptive, Expressive
Language: None, Word finding problems, Repetitive,
Confabulation, Incomprehensible Unable: Read, Write Unable: Recognize familiar faces, what to do with familiar objects
Family/Friends: Contact: None, Little, Frequent
Grief/Loss: Family, Friend, Other
Functional: Mobility: Self, 1 assist, 2 assist, Immobile Device: W/C: self, W/C assist, Cane, Walker, Motorized chair,
Other: _______________________
Toilet: Self, w/assist
Transfer: Self, w/1 assist, w/2 assist, lift
Physical: Amputation Prosthesis Contractures Impaired ROM Fatigue Lacks endurance Fall risk
Paralysis: Left, Right, bi-lateral Medical Devices: Splint, Urinary Catheter, Oxygen, Feeding tube, Cast IV
Psychiatric/Emotional: Anxiety PTSD Depression Easily frustrated
Fears: ________________________
Suspicious
Delusions Paranoia Flat affect Hallucinations Others: __________________________________
Sensory: Hearing Impairment: Mild, Significant, Hearing aide
Visual Impairment: Mild, Significant, Wears glasses
Pain: Mild, Severe, Persistent, Acute, Location: _________________________________
Social: Cooperates Interacts w/objects
Interacts: 1 on 1, small group, large group
Passive or Active in groups
Has Friends: In facility, in community, at a distance: _______________________________________________________
Spiritual: Participates in Religion Content w/spirituality Not important
Preferences (MDS Section F)
Animals: ________________________________________________________________________________________
Books & Magazines: _______________________________________________________________________________
Favorite Activity: __________________________________________________________________________________
Music:___________________________________________________________________________________________
News:_____________________________________________________________________________________________
Wants to discuss community living: _____________________________________________________________________
Continence (Section H) ____________________________________________________________________________
Other Considerations
Pain (Section J) __________________________________________________________________________________
Encouragements needed: None Normal Additional Much
Assistance Needed: None Verbal
Demonstration Hand-over-Hand
Medical Devices/Considerations: Cast
Splint
© 2011 Buettner, Connolly & Richeson, 2011
Oxygen Urinary catheter
Feeding Tube
IV Line Legs Elevated
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Buettner Assessment of Needs, Diagnoses and Interests
for Recreation Therapists in LTC
Name: _________________________
Section 6: Care Plan
Problems:
Strengths:
Recreation Therapy Care Plan (see instructions)
Goal
Intervention
Evaluation
Group/Individual Treatment
Adult Education
Animal Assisted Therapy
Aquatic Exercise
Arts, Crafts, Creative
Bibliotherapy
Clubs/Social Groups
Cognitive Therapy
Community Re-entry
Exercise/Walking/Dance
Expressive Arts
Health Promotion
Horticulture
Journaling
Music
New Resident Transition Group
Relaxation
Physician Order: RT ____ x qw for _____ weeks for ____minutes for treatment of
Reminisce/Story telling
Sensory Integration
Support Group
Technology: Wii, E-mail
Therapeutic Cooking
Wheelchair Biking
Others:
____________
Permission Granted for: ___ General Activities ____ Community Outings ____ Exercise ___ Wheelchair Biking
Physician Signature Obtained ____________________________________________
Date
______________
Resident/Family Signature ________________________________________ Date: __________
Therapist Signature ______________________________________________ Date: ___________
© 2011 Buettner, Connolly & Richeson, 2011
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Buettner Assessment of Needs, Diagnoses and Interests
for Recreation Therapy in LTC
Name: _______________________________________________________________ Room # ________
Flow Sheet
Improved ambulation AEB
walking 50’ with 1 assist
Therapeutic
Dance
Notes
Minutes
Example
7/12/2011
Intervention
Engagement
Goal
Attendance
Date
W
A
30
Enjoys group, able to participate for 15 minutes
without a break. Eval on 7/11: Able to walk 30 feet.
Attendance: W = Willingly E= Needs Encouragement R= Refused
Engagement: P= Passive A= Active Minutes: Record Minutes engaged
Notes: Use to record prompting needed, behaviors, progress toward goal, goal achievement or anything else related to
resident and/or participation.
*AEB = as evidenced by
© 2011 Buettner, Connolly & Richeson, 2011
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