Structures OT evaluation with ADL assessment, adaptive equipment needs, and work readiness evaluation. Use when conducting OT assessments, evaluating ADL independence, or recommending adaptive equipment.
Structures occupational therapy evaluation using the OTPF-4 (Occupational Therapy Practice Framework, 4th edition) including ADL and IADL performance analysis, upper extremity functional assessment, cognitive-perceptual screening, adaptive equipment recommendations, and home/work environment evaluation.
Occupational therapy assessment determines a person's ability to perform the daily activities that matter to them — self-care, home management, work, and community participation. OT evaluation drives adaptive equipment prescriptions, home modification recommendations, return-to-work decisions, and level-of-care determinations. CMS and commercial payers require OT documentation to demonstrate occupational performance deficits linked to the medical diagnosis, skilled OT assessment need, and functional outcome potential. Inadequate documentation — listing impairments without connecting them to occupational performance — results in claim denials and fails to capture the OT-specific contribution to rehabilitation. This skill produces evaluation documentation structured per the OTPF-4 framework.
Before beginning OT assessment, confirm:
Required documents:
The occupational profile captures the client's perspective:
Basic ADLs (observe actual performance, do not rely on self-report alone):
| ADL | Assessment Components | Scoring Method |
|---|---|---|
| Bathing/showering | Transfer in/out, reach all body parts, manage faucets, soap, washcloth | FIM (1-7) or assist level |
| Dressing (upper body) | Don/doff shirt, bra, manage fasteners, reach behind | FIM or assist level + time |
| Dressing (lower body) | Don/doff pants, socks, shoes, reach feet, manage closures | FIM or assist level |
| Grooming | Oral care, hair care, shaving, makeup, nail care | FIM or assist level |
| Feeding/eating | Utensil use, cup management, cutting food, bringing to mouth | FIM or assist level |
| Toileting | Clothing management, hygiene, transfer on/off toilet | FIM or assist level |
| Functional mobility | Bed mobility, transfers (bed, chair, toilet, tub) | FIM or assist level |
Instrumental ADLs (interview and performance-based):
Standardized ADL assessments:
UE motor assessment:
Standardized UE assessments:
Cognitive screening (OT-specific functional cognition):
Perceptual assessment (especially post-stroke):
Based on assessment findings, document specific recommendations:
Self-care adaptive equipment:
Home modification recommendations:
Documentation format for equipment recommendations: "Based on right hemiparesis with grip strength 15 lbs (vs. L 65 lbs) and FIM self-care scores of 3-4, the following adaptive equipment is recommended to enable supervised-to-modified-independent ADL performance: [list specific items with clinical justification]."
Before finalizing OT assessment documentation: