Occupational Therapy Initial Evaluation & Plan of Care

Date: [Date of evaluation]

Time: [Start–Stop / Total minutes per setting requirements]

Location/Setting: [Evaluation setting]

Patient Name: [Patient full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Rendering Therapist: [Name, credentials, license #]

Referring Provider: [Name, credentials]

Referral Date: [Date]

Reason for Referral: [Brief phrase from order]

Medical Diagnosis: [ICD-10 code(s) and description as available]

OT Problem Focus: [Functional problem statement tied to occupation(s)]

Precautions/Restrictions: [Weight-bearing status, movement restrictions, bracing, lines/tubes, vitals parameters, seizure/fall precautions] (Write "None identified" if none apply.)

Reason for Referral

[Narrative summary combining chief concern and context] (2–5 sentences. Include the patient's chief concern in their own words when available. Describe precipitating event/onset and why referral occurred now. Identify primary occupational consequences—what the patient cannot do or does unsafely. Attribute sources as patient report, caregiver report, and/or chart review. If unclear, explicitly state that the reason for referral is unclear rather than inferring.)

Occupational Profile

[Patient-identified concerns and reasons for seeking OT services] (Distinguish patient report from caregiver report throughout this section.)

[Occupations where the patient succeeds and current barriers to participation] (Summarize ADLs/IADLs, work/school, leisure, and social participation priorities.)

[Relevant occupational history: roles, routines, meaningful activities] (Include changes in roles/routines post-onset.)

[Values, interests, motivators] (Use brief direct quotes for patient-stated goals and values.)

[Environmental context: home setup, accessibility, transportation, workplace/school demands] (Include assistive tech or supports currently available.)

[Current performance patterns and recent changes to habits/routines]

[Patient-identified factors affecting engagement: pain, fatigue, anxiety, cognitive complaints, vision, sensory factors, sleep]

[Patient priorities and desired outcomes, ranked if possible] (Note agreement or divergence between patient and caregiver priorities.)

(If profile not fully obtained due to time or patient condition, document extent obtained and reason; add "Occupational profile to be completed next visit.")

Relevant History

• [Pertinent medical/surgical history with dates] (Include only items that directly influence OT evaluation and plan.)
• [Prior Level of Function (PLOF) for key occupations]
• [Prior therapy services and outcomes]
• [Current equipment/assistive devices in use]
• [Medications affecting function or safety] (Sedating medications, anticoagulants per facility policy.)
• [Social supports and caregiver availability/capacity]

(Use explicit placeholders if information is missing: "Unable to obtain—patient unable to report" or "Chart review limited.")

Occupational Performance Analysis

(Use a consistent assistance scale: Independent / Modified Independent / Supervision / Contact Guard / Minimal Assistance / Moderate Assistance / Maximal Assistance / Dependent. Document devices/adaptations used, key limiting factors, and safety concerns. Clearly label PLOF vs CLOF.)

Functional Performance

ADLs (feeding, grooming, bathing, dressing, toileting, hygiene)

• [ADL Task]: PLOF: [Assistance level and usual method]. CLOF: [Assistance level], [Device/adaptation], [Limiting factors], [Safety concerns].

(Include only tasks assessed. Use "Not assessed—[reason]" when a relevant task was omitted.)

IADLs (meal preparation, medication management, household tasks, community mobility, shopping, financial management)

• [IADL Task]: PLOF: [Assistance level/method]. CLOF: [Assistance level], [Device/adaptation], [Limiting factors], [Safety concerns].

Functional Mobility (as related to ADL/IADL performance)

• Bed mobility: PLOF [Level]. CLOF [Level], [Device], [Limiting factors], [Safety concerns].
• Transfers (bed↔chair/toilet/shower): PLOF [Level]. CLOF [Level], [Technique], [Device], [Limiting factors], [Safety concerns].
• Household mobility: PLOF [Distance/Level]. CLOF [Distance/Level], [Device], [Endurance], [Balance], [Safety concerns].

Work/Education Participation (if applicable)

• [Role/tasks]: PLOF [Role demands and independence]. CLOF [Current capacity], [Accommodations], [Barriers].

Leisure and Social Participation

• [Activities]: PLOF [Frequency/independence]. CLOF [Current engagement], [Barriers], [Supports].

Safety Awareness and Judgment

• [Observed safety behaviors]: [Findings], [Cueing needed], [Risks identified].

Standardized Assessments

(For each assessment: document test name/version, administration conditions, score with units, and clinical interpretation. Include only assessments performed.)

• [Assessment name]: [Conditions], [Score/results], [Functional interpretation].

(Common assessment domains: ROM/strength as relevant to function, grip/pinch strength, fine motor coordination/dexterity, sensation/vision screening, pain, edema/skin integrity, cognitive/psychosocial screening. If a clinically relevant assessment was not performed, state explicitly why.)

Task Analysis

[Brief analysis of a representative occupation or task] (Describe the task steps, where performance breaks down, observed compensations, required cues/assistance, and primary contributing impairments limiting success.)

Assessment

[Synthesis of findings] (1–3 concise paragraphs. Summarize key functional limitations with underlying contributors. Identify patient strengths and supports. Note barriers such as comorbidities, cognition, environment, or adherence risks. Provide skilled OT justification—explain why skilled OT is required rather than stating the patient "will benefit from therapy." State prognosis [good / fair / guarded] with brief rationale. Do not diagnose outside OT scope; if making clinical inferences, cite supporting evidence.)

Problem List (Order by severity and patient priorities. Format: occupational problem + measurable functional deficit + key contributor.)

1. [Problem: Occupational problem + measurable functional deficit + key contributor(s)]
2. [Problem: Occupational problem + measurable functional deficit + key contributor(s)]
3. [Problem: Occupational problem + measurable functional deficit + key contributor(s)]

Goals

Long-Term Goals (LTGs) (Episode-level targets. Each goal must include: occupation/task with context, measurable criteria, conditions including device/cueing, and timeframe.)

• LTG1: [Target occupation/context]; [Performance criteria: assistance level/time/accuracy/safety behaviors]; [Conditions: device/adaptation/cueing]; [Timeframe].
• LTG2: [Participation-level goal if applicable: community/work/school]; [Measurable criteria]; [Conditions]; [Timeframe].

Short-Term Goals (STGs) (Stepping stones toward LTGs.)

• STG1: [Task/skill]; [Performance criteria]; [Conditions]; [Timeframe].
• STG2: [Task/skill]; [Performance criteria]; [Conditions]; [Timeframe].
• [Caregiver competency goal if applicable]: Caregiver will demonstrate [skill] with [accuracy/independence level] under [conditions] by [timeframe].

(If goals cannot be finalized due to patient status: "Goals deferred—patient unable to participate; to establish next visit." Label any provisional clinician-identified goals as such.)

Plan of Care

Frequency: [Sessions per week]

Duration: [Number of weeks or visits]

Anticipated Discharge Timeframe: [Date or criteria-based timeframe]

Discharge Criteria: [Functional or goal-based criteria]

Planned Interventions (Include only interventions planned for this episode.)

• [ADL/IADL training with compensatory strategies and adaptive equipment]
• [Therapeutic activities targeting functional performance]
• [Therapeutic exercise tied to occupational outcomes]
• [Neuromuscular re-education]
• [Cognitive strategy training and executive function supports]
• [Vision/perceptual interventions]
• [Sensory-based approaches]
• [Manual techniques within scope]
• [Orthotic/splint fabrication: type, wear schedule, skin check plan]
• [Modalities with functional rationale]

Home Program

• [Items issued this visit]
• [Patient/caregiver understanding and demonstration of competency]
• [Barriers to carryover identified and plan to address]

Education

• [Condition education provided]
• [Precautions and safety training]
• [Energy conservation / pacing / work simplification as applicable]
• [Caregiver training plan]

Coordination of Care

• [Plan for communicating with referring provider for certification]
• [Interdisciplinary coordination: PT, SLP, nursing, case management, others]
• [Community resources/referrals as indicated]

Signature

Therapist Signature: [Name and signature]

Credentials: [OTR/L, license #]

Date/Time Signed: [MM/DD/YYYY HH:MM]

(If an OT assistant participated in the evaluation, document: OTA name, credentials, and specific role.)