Occupational Therapy Evaluation Template

A comprehensive OT initial evaluation template with all required sections: occupational profile, performance analysis, standardized assessments, goals, and treatment planning. Free to use and customize for your practice.

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What is an Occupational Therapy Evaluation?

An occupational therapy evaluation is a comprehensive assessment that examines a client's ability to perform meaningful daily activities (occupations). Unlike assessments in other disciplines that focus primarily on body functions, OT evaluations take a holistic, client-centered approach that considers the whole person within their unique contexts and environments.

The OT evaluation establishes the foundation for all subsequent treatment. It identifies what matters most to the client, what they can and cannot do, why they are experiencing difficulties, and how occupational therapy can help them achieve their goals.

The OT Evaluation Answers Key Questions:

What occupations are meaningful to this client? - Understanding their roles, routines, and priorities
What can and cannot the client do? - Current performance in ADLs, IADLs, work, leisure, and social participation
Why is the client having difficulty? - Identifying underlying performance skills, patterns, and client factors
What are the client's goals? - Collaborative goal-setting based on client priorities
What is the best intervention approach? - Developing an occupation-based treatment plan

When is an OT Evaluation Required?

An occupational therapy evaluation is required in the following situations:

Initial referral: When a client is first referred for OT services
Change in condition: Significant improvement or decline requiring reassessment
New diagnosis or comorbidity: Additional conditions affecting function
Transfer between settings: Moving from acute care to rehab, rehab to home health, etc.
Annual reassessment: Required in some settings for ongoing services

Scope of Practice Reminder

OT evaluations must be performed by a licensed Occupational Therapist (OT/OTR). COTAs can assist with data collection under supervision, but the interpretation, goal-setting, and treatment planning must be completed by the OT.

Components of an OT Evaluation

According to the Occupational Therapy Practice Framework (OTPF-4), an OT evaluation consists of two main components: the occupational profile and the analysis of occupational performance.

1. Occupational Profile

The occupational profile is a summary of the client's occupational history, patterns of daily living, interests, values, and needs. It is gathered primarily through interview and provides the context for understanding the client's perspective.

Occupational Profile Includes:

Reason for referral: Why the client is seeking OT services
Occupational history: Past and current engagement in occupations
Daily routines and roles: Typical day structure and responsibilities
Interests and values: What matters most to the client
Priorities and goals: What the client wants to achieve
Supports and barriers: Environmental and social factors
Contexts: Cultural, personal, temporal, and virtual contexts

2. Analysis of Occupational Performance

The analysis of occupational performance involves observing the client perform meaningful occupations and activities to identify what supports or hinders performance. This includes assessment of:

Occupations: ADLs, IADLs, rest/sleep, education, work, play, leisure, social participation
Performance Skills: Motor skills, process skills, social interaction skills
Performance Patterns: Habits, routines, roles, rituals
Client Factors: Values, beliefs, body functions, body structures
Context and Environment: Physical, social, cultural, personal, temporal, virtual

3. Standardized Assessments

In addition to observation and interview, OT evaluations typically include standardized assessments that provide objective, measurable data. Assessment selection depends on the client population, setting, and specific areas of concern.

4. Clinical Reasoning and Interpretation

The OT synthesizes all gathered information to form a clinical picture of the client's strengths, deficits, and potential for improvement. This reasoning guides goal development and treatment planning.

5. Goals and Treatment Plan

Based on the evaluation findings and in collaboration with the client, the OT develops measurable goals and an intervention plan that addresses identified needs and aligns with client priorities.

Complete OT Evaluation Template

Below is a comprehensive occupational therapy evaluation template that you can use as a guide or customize for your practice setting. This template follows the OTPF-4 framework and includes all essential components for a thorough initial evaluation.

Occupational Therapy Initial Evaluation

Confidential Patient Information

Patient Demographics

Patient Name: _______________

DOB: _______________

MRN: _______________

Evaluation Date: _______________

Referring Physician: _______________

Primary Diagnosis: _______________

ICD-10 Code: _______________

Secondary Diagnoses/PMH: _______________

Precautions/Contraindications: _______________

Reason for Referral

Describe reason for OT referral, including onset, mechanism of injury/illness, and specific functional concerns:

_________________________________________________________________

Occupational Profile

Prior Level of Function (PLOF)

Describe client's functional abilities prior to current condition (living situation, independence in ADLs/IADLs, work status, mobility):

_________________________________________________________________

Living Situation

Lives alone Lives with spouse/partner Lives with family Lives with caregiver

Home environment details (stairs, bathroom setup, DME): _______________

Roles and Responsibilities

Current roles (parent, spouse, worker, caregiver, etc.) and responsibilities:

_________________________________________________________________

Daily Routine

Describe typical daily routine including wake/sleep times, meals, activities, and rest periods:

_________________________________________________________________

Interests and Leisure Activities

Hobbies, interests, and leisure pursuits (past and current):

_________________________________________________________________

Client's Goals and Priorities

What are the client's primary goals for occupational therapy? What matters most to them?

_________________________________________________________________

Support Systems

Available supports (family, friends, caregivers, community resources):

_________________________________________________________________

Analysis of Occupational Performance

Activities of Daily Living (ADLs)

ADL Area	Level of Assistance	Comments/Observations
Bathing/Showering	I / SBA / Min A / Mod A / Max A / Total A
Dressing - Upper Body	I / SBA / Min A / Mod A / Max A / Total A
Dressing - Lower Body	I / SBA / Min A / Mod A / Max A / Total A
Grooming	I / SBA / Min A / Mod A / Max A / Total A
Oral Hygiene	I / SBA / Min A / Mod A / Max A / Total A
Toileting	I / SBA / Min A / Mod A / Max A / Total A
Toilet Hygiene	I / SBA / Min A / Mod A / Max A / Total A
Feeding/Eating	I / SBA / Min A / Mod A / Max A / Total A
Functional Mobility	I / SBA / Min A / Mod A / Max A / Total A

Instrumental Activities of Daily Living (IADLs)

IADL Area	Level of Assistance	Comments/Observations
Meal Preparation	I / SBA / Min A / Mod A / Max A / Total A / N/A
Medication Management	I / SBA / Min A / Mod A / Max A / Total A / N/A
Light Housekeeping	I / SBA / Min A / Mod A / Max A / Total A / N/A
Laundry	I / SBA / Min A / Mod A / Max A / Total A / N/A
Shopping	I / SBA / Min A / Mod A / Max A / Total A / N/A
Financial Management	I / SBA / Min A / Mod A / Max A / Total A / N/A
Driving/Transportation	I / SBA / Min A / Mod A / Max A / Total A / N/A

Client Factors Assessment

Cognition

Orientation: Person / Place / Time / Situation

Attention: WFL / Mildly impaired / Moderately impaired / Severely impaired

Memory observations (short-term, long-term, procedural): _______________

Executive function observations (problem-solving, judgment, sequencing): _______________

Cognitive screening results (if administered): _______________

Vision and Perception

Visual acuity: WFL / Corrected / Impaired

Glasses/contacts: Yes / No

Visual-perceptual observations (neglect, scanning, figure-ground, depth perception): _______________

Upper Extremity Motor Function

Assessment	Left	Right
Shoulder AROM Flexion	____ degrees	____ degrees
Shoulder AROM Abduction	____ degrees	____ degrees
Elbow AROM Flexion/Extension	____/____	____/____
Wrist AROM Flexion/Extension	____/____	____/____
Grip Strength	____ lbs	____ lbs
Lateral Pinch	____ lbs	____ lbs
Tip Pinch	____ lbs	____ lbs

Muscle tone (normal, hypotonia, hypertonia/spasticity): _______________

Coordination and fine motor observations: _______________

Sensation

Light touch: Intact / Impaired / Absent

Sharp/dull: Intact / Impaired / Absent

Proprioception: Intact / Impaired / Absent

Stereognosis: Intact / Impaired / Absent

Sensory observations/areas of impairment: _______________

Pain

Pain level at rest: ____/10

Pain level with activity: ____/10

Pain location and description: _______________

Standardized Assessments Administered

List all standardized assessments administered with scores and interpretations:

Assessment: _________________ Score: _________ Interpretation: _________________

Assessment: _________________ Score: _________ Interpretation: _________________

Assessment: _________________ Score: _________ Interpretation: _________________

Clinical Summary and Interpretation

Strengths

Identify client's strengths and intact abilities:

_________________________________________________________________

Problem List

Prioritized list of occupational performance deficits:

1. _________________________________________________________________

2. _________________________________________________________________

3. _________________________________________________________________

Rehabilitation Potential

Excellent Good Fair Poor

Rationale for rehabilitation potential: _______________

Occupational Therapy Goals

Short-Term Goals (2-4 weeks)

1. Patient will _____________ with _____________ assistance to _____________ within _____ weeks.

2. Patient will _____________ with _____________ assistance to _____________ within _____ weeks.

3. Patient will _____________ with _____________ assistance to _____________ within _____ weeks.

Long-Term Goals (Discharge Goals)

1. Patient will _____________ independently/with _____________ to _____________ by discharge.

2. Patient will _____________ independently/with _____________ to _____________ by discharge.

Therapist Signature

Evaluating Therapist: _______________

Credentials: OTR/L, _______________

Signature: _______________

Date: _______________

Tips for Writing OT Evaluations

A well-written OT evaluation not only supports clinical decision-making but also ensures reimbursement, communicates effectively with the care team, and creates a defensible legal document. Here are essential tips for writing effective evaluations.

1. Start with the Client's Perspective

Document the client's goals and priorities early in the evaluation. What matters to them should drive the entire evaluation and treatment plan. Use their own words when possible.

2. Be Specific and Measurable

Use objective measurements whenever possible. "Grip strength 15 lbs" is better than "weak grip." "Requires moderate assistance for upper body dressing" is better than "needs help dressing."

3. Document the "Why" Behind Deficits

Don't just list what the client cannot do - explain why. "Patient requires mod A for lower body dressing due to decreased hip flexion ROM and impaired sitting balance secondary to CVA." This demonstrates clinical reasoning and skilled need.

4. Connect Deficits to Occupational Performance

Always tie impairments back to functional limitations. "Decreased fine motor coordination limiting ability to manage buttons and zippers independently for dressing." This shows the occupation-based focus of OT.

5. Write SMART Goals

Goals should be Specific, Measurable, Achievable, Relevant, and Time-bound. "Patient will complete upper body dressing with modified independence using adaptive equipment within 2 weeks" meets all criteria.

6. Justify Medical Necessity

Clearly document why skilled OT services are required. What can you provide that the client cannot do on their own or with a caregiver? This is essential for insurance approval.

7. Include Both Strengths and Limitations

A balanced evaluation acknowledges what the client does well, not just their deficits. Strengths inform your treatment approach and help identify compensatory strategies.

Common Mistakes to Avoid

Avoid vague language ("patient is weak"), copying evaluations between patients, failing to document prior level of function, writing goals the patient cannot achieve, and forgetting to include the client's perspective and priorities.

Common Standardized Assessments for OT Evaluations

Selecting appropriate standardized assessments strengthens your evaluation by providing objective, measurable data. Here are commonly used assessments organized by category.

Functional/ADL Assessments

Functional Independence Measure (FIM): 18-item measure of physical, cognitive, and psychosocial disability
Barthel Index: 10-item ADL measure commonly used in rehab settings
Katz Index of Independence in ADLs: Assesses independence in 6 basic ADLs
Lawton IADL Scale: Assesses 8 instrumental activities of daily living
COPM (Canadian Occupational Performance Measure): Client-centered outcome measure

Cognitive Assessments

MoCA (Montreal Cognitive Assessment): Brief cognitive screening tool
MMSE (Mini-Mental State Examination): Brief cognitive screening
Allen Cognitive Level Screen (ACLS): Assesses functional cognition
Trail Making Test (A and B): Assesses attention and executive function
Lowenstein Occupational Therapy Cognitive Assessment (LOTCA): Comprehensive cognitive battery

Motor and Hand Function Assessments

Grip and Pinch Dynamometry: Objective strength measurement
9-Hole Peg Test: Fine motor coordination and dexterity
Box and Block Test: Gross manual dexterity
Jebsen-Taylor Hand Function Test: Functional hand use
Purdue Pegboard: Fine motor speed and dexterity
Action Research Arm Test (ARAT): Upper extremity function post-stroke

Visual-Perceptual Assessments

Motor-Free Visual Perception Test (MVPT): Visual perception without motor demands
Test of Visual Perceptual Skills (TVPS): Visual perceptual abilities
Catherine Bergego Scale: Unilateral neglect assessment
Line Bisection Test: Screen for visual neglect

Sensory Assessments

Semmes-Weinstein Monofilament Test: Light touch threshold
Two-Point Discrimination: Tactile discrimination
Sensory Profile: Sensory processing patterns (adult and pediatric versions)

Balance and Fall Risk

Berg Balance Scale: Balance assessment
Timed Up and Go (TUG): Functional mobility and fall risk
Activities-Specific Balance Confidence Scale (ABC): Self-reported balance confidence

Assessment Selection Tip

Choose assessments based on the client's diagnosis, setting requirements, and your evaluation questions. You don't need to administer every assessment - select those that will provide the most useful information for treatment planning.

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OT Evaluation FAQ

What should be included in an OT evaluation?

An OT evaluation should include an occupational profile (client's history, priorities, and goals), analysis of occupational performance (observation of ADLs, IADLs, and meaningful activities), standardized assessments (cognitive, motor, sensory tests as appropriate), clinical reasoning and interpretation of findings, functional goals aligned with client priorities, and a comprehensive treatment plan.

How long should an OT evaluation take?

An OT evaluation typically takes 45-60 minutes for a standard evaluation, though complex cases may require 90 minutes or more. Documentation time adds an additional 30-60 minutes depending on your EHR system and documentation requirements. Using AI documentation tools like SOAP Note Buddy can reduce documentation time significantly.

What is the difference between an OT evaluation and an OT screening?

An OT screening is a brief review (typically 15-20 minutes) to determine if a full evaluation is warranted. It identifies potential concerns but does not establish goals or a treatment plan. An OT evaluation is a comprehensive assessment that includes occupational profile, performance analysis, standardized testing, goal setting, and treatment planning. An evaluation is required before initiating OT services.

Can COTAs perform OT evaluations?

No, OT evaluations must be performed by a licensed Occupational Therapist (OT/OTR). COTAs can contribute to the evaluation process by gathering data and administering certain assessments under OT supervision, but the evaluation interpretation, goal setting, and treatment planning must be completed and signed by the OT.

What standardized assessments are commonly used in OT evaluations?

Common OT assessments include the FIM (Functional Independence Measure), Barthel Index, COPM (Canadian Occupational Performance Measure), MoCA (Montreal Cognitive Assessment), grip/pinch dynamometry, 9-Hole Peg Test, Box and Block Test, and various ADL and sensory assessments. Assessment selection depends on the setting, client population, and specific areas of concern.

How do I write occupation-based OT goals?

Occupation-based goals should be tied to meaningful activities the client wants or needs to do. Instead of "Patient will improve grip strength to 20 lbs," write "Patient will open food containers independently for meal preparation using improved grip strength." The goal should be SMART: Specific, Measurable, Achievable, Relevant, and Time-bound.

How often should OT re-evaluations be completed?

Re-evaluation frequency depends on setting requirements and payer guidelines. Medicare typically requires re-evaluation every 30 days or when there is a significant change in condition. Many facilities require re-evaluation at certification periods (every 60-90 days). Always check your specific payer and setting requirements.

Is this OT evaluation template free to use?

Yes, this OT evaluation template is free to use and customize for your practice. You can print it, save it, or adapt it to your specific setting requirements. For AI-powered auto-filling of your EHR's evaluation forms, try SOAP Note Buddy free for 3 days.

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