Occupational Therapy Acute Care Initial Evaluation

Date/Time of Service: [Date and time of encounter]

Patient Name: [Full legal name]

MRN: [Medical record number]

Location/Unit: [Unit/room/bed]

Evaluating Therapist: [Name, credentials (e.g., OTR/L)]

Referral Source and Date: [Referring provider/service and order date]

Interpreter Used: [Language and modality] (Omit this line entirely if no interpreter used.)

Reason for OT Consult

[Reason for consultation] (2–4 sentences anchoring to hospitalization. Include admitting diagnosis, relevant procedure with post-op day if applicable, and the primary functional concerns prompting OT involvement such as new ADL dependence, cognitive/safety concerns, precautions impacting self-care, or discharge planning needs.)

Precautions & Activity Parameters

(List safety-critical information relevant to OT. If no OT-relevant precautions exist, state "No OT-relevant precautions identified at time of evaluation.")

• [Weight-bearing status and orthopedic restrictions] (e.g., WBAT, NWB, ROM limits, bracing)
• [Medical precautions] (e.g., fall risk, aspiration, seizure, sternal, spinal, isolation type/PPE)
• [Lines/tubes/drains/devices pertinent to mobility and self-care] (e.g., IV, central line, Foley, drains, chest tube, NG/PEG, oxygen, telemetry)
• [Activity orders and hemodynamic parameters] (e.g., up ad lib vs. bedrest; HR/SBP/SpO2 thresholds)

Subjective

[Patient-stated goals and priorities] (Include a brief direct quote when impactful. Note pain rating and location as it affects function, and any pain interventions during session. Specify information source if not patient.)

• Prior Level of Function: [ADL and mobility baseline] (Self-care independence, typical assistance, baseline cognition; community vs. household mobility)
• Home Environment: [Dwelling type, stairs with rails, bathroom setup] (tub/shower, grab bars, toilet height, entry access)
• Living Situation: [Lives alone/with others; caregiver availability and capacity]
• Baseline Equipment: [Existing DME] (e.g., shower chair, commode, walker, wheelchair)
• Information Source: [Patient / family / chart / case management] (Note reliability and knowledge gaps; include targeted follow-up questions if key discharge information is unknown.)

Objective

Cognition & Safety Awareness

[Cognitive and safety status] (Orientation to person/place/time/situation; arousal and attention; ability to follow commands; memory relevant to learning and carryover; judgment and safety awareness including awareness of lines and precautions; problem-solving during ADL tasks. Note communication barriers. If a standardized screen was used, include tool name, score, and brief interpretation. Describe specific observed behaviors when cognition impacts safety or discharge planning.)

Physical & Sensorimotor Status

[Focused findings relevant to function] (Gross UE ROM/strength, coordination, sensation, tone, edema, vision/perceptual concerns as they affect ADLs. Include activity tolerance and physiologic response—vitals, symptoms with position change, endurance—when medically relevant or when tolerance limits function. Keep concise.)

Sitting and Standing Balance

• Sitting Balance – Static: [Assistance level]; [UE support: none / one hand / bilateral]; [key observations]
• Sitting Balance – Dynamic: [Assistance level]; [reach tolerance]; [loss of balance or cues needed]
• Standing Balance – Static: [Assistance level]; [assistive device]; [UE support]; [guarding level]
• Standing Balance – Dynamic: [Assistance level]; [assistive device]; [task demands]; [safety concerns]

Functional Mobility

• Bed Mobility: [Task(s)] – [Assistance level x1/x2] with [device/bed features]; [limiting factors]; [safety concerns]
• Sit-to-Stand: [Assistance level x1/x2]; [assistive device]; [cues type/frequency]; [tolerance]
• Transfers: [Surface: bed / toilet / commode / chair] – [Assistance level x1/x2]; [technique]; [device]; [limiting factors]
• In-Room Ambulation: [Distance]; [assistance level x1/x2]; [device]; [gait quality]; [activity tolerance]

(If a task was deferred, document why and whether follow-up is planned.)

ADL Performance

• Grooming: [Assistance level]; [performed / simulated / estimated]; [equipment]; [cues type/frequency]
• Upper Body Dressing: [Assistance level]; [performed / simulated / estimated]; [precaution adherence]; [equipment/technique]; [cues]
• Lower Body Dressing: [Assistance level]; [performed / simulated / estimated]; [assistive equipment]; [balance/tolerance]; [cues]
• Toileting/Toilet Hygiene: [Assistance level]; [performed / simulated / estimated]; [hygiene and clothing management]; [DME]; [cues]
• Bathing: [Assistance level]; [performed / simulated / estimated]; [seated / standing]; [equipment]; [safety concerns]
• Feeding/Self-Feeding: [Assistance level]; [positioning]; [adaptive utensils]; [cues] (Include when within OT scope for this encounter.)

(When estimating, explicitly state rationale: prior performance observed, chart history, or caregiver report.)

Standardized Outcome Measure

(Include if a standardized measure was administered.)

[Tool name] (e.g., AM-PAC 6-Clicks Daily Activity) – [Score]: [Brief interpretation related to functional status and discharge planning] (Do not use score alone to determine disposition.)

Education Provided

• Topics: [Topics covered] (e.g., precautions, equipment use, fall prevention, ADL strategies, energy conservation)
• Method: [Verbal / demonstration / teach-back / written materials]
• Learner Response: [Patient/caregiver understanding, return demonstration ability, need for reinforcement]

Assessment

[Clinical synthesis] (1–3 short paragraphs. Begin with a summary of current functional status and key assistance levels across mobility and ADLs. Identify primary OT problems limiting occupational performance—safety/cognition, precautions, activity tolerance, balance, pain, ADL dependence. Explain why skilled OT is required versus unskilled care. State prognosis and rehabilitation potential with moderating factors.)

Discharge Recommendations: [Recommended discharge setting] with justification based on observed function and cognitive/safety status; [recommended caregiver support and supervision needs]; [recommended DME/adaptive equipment] with rationale; [barriers to discharge plan]; [alternative plan if primary recommendation is not feasible]. (Use behavior-based and assistance-based language rather than "safe" or "unsafe." Clearly distinguish observations from inferences and label anticipated needs with stated assumptions.)

Goals

(Omit this section entirely if no further OT indicated; instead document that acute OT needs are met with the discharge plan.)

• By [timeframe], patient will [functional task in occupation-based language] with [assistance level], using [equipment/device], adhering to [precautions].
• By [timeframe], patient will [transfer or mobility task for self-care access] with [assistance level x1/x2], using [assistive device], with [safety criteria].
• By [timeframe], patient/caregiver will demonstrate [education topic] via [teach-back / return demonstration] with [cue level].

Plan

Frequency/Duration: [X sessions/week for anticipated length of stay or until discharge/goal attainment]

• ADL retraining: [priority tasks]
• Functional transfers and mobility for self-care access
• Cognitive and safety strategies (if indicated)
• DME/adaptive equipment assessment, recommendations, and training
• Patient and caregiver education: [priority topics]
• [Other interventions as indicated] (e.g., energy conservation, edema management, splinting, positioning)
• Coordination: [Case management, nursing recommendations, caregiver training sessions needed prior to discharge]

(If discharge is imminent, note urgency and prioritize caregiver training, equipment, and safety planning. If patient is medically unstable, plan to re-evaluate with criteria for progression.)

Assistance Level Legend

(Include on first use if abbreviations are used; align with facility terminology.)

• Independent (Ind): No assistance or cues
• Modified Independent (Mod I): Device or extra time, no physical help
• Supervision (Sup) / Standby Assist (SBA): Within arm's reach, no physical contact
• Contact Guard Assist (CGA): Light touch for steadying
• Minimal Assist (Min A): Patient performs ≥75% of effort
• Moderate Assist (Mod A): Patient performs 50–74% of effort
• Maximal Assist (Max A): Patient performs 25–49% of effort
• Total Assist/Dependent: Patient performs <25% of effort
• Two-person assist: x2