Occupational Therapy Evaluation Documentation Examples
Dr. Medeline Yost
Chief Medical Officer, Augustun
Published June 23, 2026
Updated June 23, 2026
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OT evaluations set the trajectory for everything that follows: treatment frequency, intervention selection, goal quality, and payer justification.
A strong evaluation note should be function-centered, measurable, and explicit about skilled need. The examples below are designed for practical use across common OT settings.
Essential Sections in an OT Evaluation Note
- Reason for referral and occupational profile
- Current level of function and participation limits
- Objective findings (performance, strength, ROM, cognition, etc.)
- Clinical assessment and problem list
- Goals and treatment plan with frequency/duration
Evaluation Example Summaries by Setting
| Setting | Referral Focus | Primary Measured Deficits | Plan Direction |
|---|---|---|---|
| Pediatrics | Fine motor delay | Grip, bilateral coordination, visual-motor control | Play-based strengthening + handwriting readiness |
| School-based | Classroom participation | Legibility, task initiation, sensory regulation | IEP-linked writing and regulation supports |
| SNF | Post-acute ADL recovery | Transfer safety, endurance, dressing/toileting dependence | ADL retraining + fall prevention |
| Home health | Safe home independence | Bathing setup, medication management, hazard risk | Home modification + caregiver training |
| Neuro rehab | Post-stroke UE function | Motor control, attention, sequencing, neglect | Task-specific retraining + compensatory strategy |
| Hand therapy | Pain and hand function | Grip/pinch strength, ROM, edema, dexterity | Splinting + graded strengthening |
Mini Evaluation Documentation Templates
Pediatric Evaluation Mini Template
- Profile
- Child presents with [participation concern] impacting [home/school/play].
- Findings
- Observed deficits in [fine motor/visual motor/sensory processing] with measurable scores [details].
- Assessment
- Deficits limit [specific occupation] and require skilled OT intervention.
- Plan
- OT [frequency] for [duration], goals focused on [functional targets].
SNF Evaluation Mini Template
- Profile
- Patient post [event] presents with reduced independence in [ADLs].
- Findings
- Current assistance levels: [details], balance/endurance deficits: [details].
- Assessment
- Functional safety risk present; skilled OT required to restore ADL capacity.
- Plan
- OT [frequency], ADL retraining + transfer safety + caregiver/staff education.
Goal Writing Tips for Evaluation Notes
- Tie goals to occupations, not only impairments.
- Use measurable targets (assist level, time, accuracy).
- Include expected timeframe and context (home/school/community).
- Ensure goals match identified deficits and plan interventions.
Common Evaluation Documentation Mistakes
- 1Too much impairment detail without participation impact.
- 2Goal statements that are not measurable.
- 3Plan frequency that is not justified by findings.
- 4No explicit skilled rationale for intervention needs.
Internal Linking Suggestions
- Daily note follow-through: Occupational Therapy SOAP Note Examples
- Workflow guide: How to Write Occupational Therapy SOAP Notes
- Broader OT docs: Occupational Therapy Documentation Guide
Conclusion
High-quality OT evaluations make treatment planning clearer and documentation easier across the full episode of care. Keep evaluation notes function-centered, measurable, and explicit about skilled clinical need.
Frequently asked questions
What is the most important part of an OT evaluation note?
The link between measured deficits and functional participation impact. This connection drives goals, treatment planning, and payer justification.
Should evaluation notes include assist levels?
Yes, especially for ADL and mobility-related settings. Assist levels provide objective baseline data for progress tracking.
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Dr. Medeline Yost
Chief Medical Officer, Augustun
Dr. Medeline Yost is an Internal Medicine physician and an emerging leader in clinical innovation. As Chief Medical Officer at Augustun, she helps shape AI-powered tools that streamline clinical documentation and support physicians in delivering higher-quality care. Her professional interests include medical education, workflow redesign, and the responsible use of AI in healthcare — building systems that let clinicians spend more time with patients and less on administrative tasks.