Functional Status (ADL/IADL) & Home Safety Assessment Note

Date: [Date of encounter]

Patient: [Patient name / DOB / MRN]

Encounter Type & Setting: [clinic visit / home visit / telehealth / SNF / caregiver collateral]

Reason for Assessment: [functional decline / falls / post-hospitalization baseline / DME need / home health eligibility / caregiver concern / other]

Informants: [List informants with names/relationships: patient, caregiver, facility staff, chart review, direct observation] (Throughout the note, label statements as Observed, Patient-reported, or Caregiver-reported when clinically relevant.)

Limitations: [Assessment limitations affecting reliability, if any] (e.g., cognitive impairment, language barrier, limited historian, no home visit/video available)

Presenting Concern & Functional Change

[Brief narrative of primary functional concern and trajectory] (Include chief concern in patient/caregiver words when helpful; baseline/prior level of function with time anchor; current functional status; onset and course with triggers; and patient-centered goals. Keep medical history minimal—only what directly explains functional change. If baseline is unknown, explicitly state this and note plan to obtain collateral.)

Functional Status — ADLs

(Use a consistent assist-level scheme: Independent / Independent with device/adaptation / Setup assist only / Supervision/cueing / Partial physical assist / Maximal assist/dependent / Unknown. Include who assists, safety concerns, and what actually happens when this adds clinical value.)

• Bathing: [Assist level] — [Method, location, safety concerns]
• Dressing: [Assist level] — [Upper vs lower body if different; adaptive devices]
• Toileting: [Assist level] — [Equipment, continence products, nighttime strategies]
• Transfers (bed/chair/toilet): [Assist level] — [Technique, need for armrests, safety issues]
• Continence: [Continent / Incontinent / Mixed / Unknown] — [Triggers, management, impact on function/safety]
• Feeding/Eating: [Assist level] — [Swallowing concerns, adaptive utensils, setup needs]

Functional Status — IADLs

(For community-dwelling patients, document current function. For facility residents, note "Not applicable in current setting" and document prior IADL function if known. Use the same assist-level scheme as ADLs. When information is unavailable, document "Unknown—collateral needed" rather than assuming independence. Note failure modes and mitigations in place.)

• Telephone use: [Assist level] — [Device type, ability to place/answer calls]
• Transportation/driving: [Assist level] — [Drives vs rides, safety concerns, alternatives]
• Shopping: [Assist level] — [List-making, payment, delivery services]
• Meal preparation: [Assist level] — [Safe stove use, microwave only, meal delivery]
• Housework/laundry: [Assist level] — [Tasks performed, hazards]
• Medication management: [Assist level] — [Pillbox/blister pack, missed doses, who supervises]
• Finances: [Assist level] — [Bill paying, auto-pay, oversight arrangements]

Mobility & Fall Risk

Mobility: [Ambulation status: independent / household only / wheelchair user / bedbound]; [Distance tolerance and limiting factors]; [Stair ability and number of steps at home]; [Transfer quality for bed/chair/toilet/tub].

Assistive Devices: [Devices used vs owned] — [Fit and safety issues; footwear concerns].

Falls & Near-Falls: [Number of falls in past 12 months]; [Most recent fall: date, location, circumstances, injury, ability to get up]; [Near-falls or balance episodes]; [Fear of falling and activity restriction]; [Dizziness or orthostatic symptoms]. (Include IADL-related safety events if applicable: missed medications, stove left on, wandering, unsafe driving.)

Standardized Testing: [Test name, result, and interpretation] (Include if performed: Timed Up and Go, chair-stand test, balance screens.)

Immediate Safety Threat: [Describe threat and same-day safety plan] (Include only if credible immediate risk identified.)

Home Safety Assessment

Assessment Method: [Home visit (in-person) / Video walkthrough / Patient/caregiver verbal report only / Prior OT assessment reviewed / Not assessed — reason]

Living Situation: [Lives alone / with others]; [Type of dwelling]; [Bedroom and bathroom location]; [Entry steps]; [Elevator access].

Home Safety Summary: [Top 3–5 highest-risk hazards identified and immediate recommendations]. (If home environment not assessed, state reason and note that general fall-prevention guidance was provided and/or OT home safety evaluation is recommended.)

Hazard Details: (Document specific findings as applicable across: pathways/flooring, lighting, stairs/handrails, bathroom safety, bedroom, kitchen, outdoor/entry, emergency preparedness. Include location, hazard description, and mitigation plan for each.)

[Hazard findings with location and mitigation plans]

Willingness & Constraints: [Patient preferences, renting/landlord constraints, cost barriers, refusals]

Support System & Caregivers

Current Supports: [Primary caregiver: name, relationship, co-residence, availability]; [Paid supports: hours, agency vs private]; [Specific care tasks performed]; [Backup plan if primary caregiver unavailable].

Gaps & Risks: [Supervision needs: safe alone? overnight? wandering risk?]; [Caregiver constraints]; [Unmet needs]. (Use neutral, factual language. Attribute concerns to specific observations or reports.)

Targeted Clinical Factors

(Briefly note only clinical contributors that directly affect function and safety. This is not a comprehensive history—include only factors driving functional limitations or safety risks.)

[Problem-oriented list of relevant contributors: pain limiting mobility; cognitive impairment affecting IADLs/safety; mood affecting motivation/activity; vision/hearing impairment; incontinence contributing to rushing/falls; medications contributing to dizziness/sedation/falls; other key factors]

Objective Observations

(Document only what was directly observed during this encounter.)

• Gait: [Quality: steady / shuffling / wide-based / turn instability] — [Distance and observations]
• Transfers: [Technique observed for bed/chair/toilet] — [Needs armrests, multiple attempts, unsafe technique]
• Assistive Device Use: [Proper/improper technique, brake use, fit issues]
• Environmental Observations: [Hazards or safe features observed] (Include if home visit or video.)

Assessment

[Concise functional summary comparing baseline to current status with key dependencies; risk stratification (e.g., high fall risk, unsafe transfers, medication management failure risk); most likely contributors (medical, environmental, support gaps); differential drivers if decline is unexplained with plan to evaluate. Lead with highest-risk issues.]

Problem List:

• [Problem 1]: [Risk level and key contributors]
• [Problem 2]: [Risk level and key contributors]
• [Additional problems as applicable]

Plan

(Organize by problem, highest safety risks first. For each problem include: interventions today, referrals with rationale, DME/equipment recommendations, counseling provided, and follow-up plan. Separate orders placed from recommendations from patient declined.)

[Problem 1]

• Interventions today: [Education, immediate hazard mitigation, activity restrictions, device adjustments]
• Referrals: [PT / OT / Home health / Social work / Fall-prevention programs / Vision / Hearing / Podiatry] — [Rationale for each]
• DME/adaptive equipment: [Specific items and rationale]
• Patient declined: [Items declined and stated reason] (Include only if applicable.)

[Additional problems as applicable]

[Repeat structure for each problem]

Counseling & Safety Planning

Counseling provided: [Fall prevention, safe transfers, device use, medication safety, other topics]

Emergency/safety plan: [How to summon help after fall, when to call 911, alert device use]

Follow-up

[Timeframe and responsible clinician/team for reassessment]

(When information is unavailable, document what is unknown and the plan to obtain it. Do not infer independence or safety when information is lacking.)