Occupational Therapy Re-Evaluation

Date/Time: [Date and time of service]

Setting: [outpatient clinic / inpatient unit / SNF / home health / school / other]

Therapist: [Therapist full name, credentials]

Patient: [Patient name and identifier per policy]

Referring Provider: [Name, credentials] (Omit if direct access without order)

Initial Evaluation Date: [Date of initial OT evaluation]

Visits Since Last Evaluation/Re-Evaluation: [Number of visits]

Primary Diagnosis/Conditions: [Primary diagnosis and pertinent conditions impacting occupational performance]

Reason for Re-Evaluation

[Qualifying trigger(s) for re-evaluation with brief justification] (Select one or more: significant change in functional or medical status; failure to progress/plateau requiring plan modification; new clinical findings affecting occupational performance; pre-discharge reassessment; new precautions/restrictions; changed context affecting performance such as environment, caregiver, or equipment.)

Scope of reassessment today: [Domains re-evaluated this visit] (If trigger details are limited, note the limitation and that objective reassessment was performed.)

Updated Occupational Profile

Chief functional concern: [One-line statement of the client's primary functional concern]

[Client-centered narrative update] (Summarize changes since prior evaluation only. Include updates to client priorities and goals—use direct quotes when documenting the client's words; changes to roles/routines/environments; current supports and barriers; client-reported symptoms impacting function. If no significant changes: "Occupational profile reviewed; no significant changes except as noted.")

Medical/Clinical Status Update

(Include only OT-relevant changes since last evaluation. If information is unavailable, note the source limitation.)

• [Hospitalizations, surgeries, exacerbations, or new diagnoses with dates]
• [Current precautions and restrictions with dates] (e.g., weight-bearing status, ROM limits, aspiration risk, splinting protocols)
• [Medication changes affecting function or safety with dates]
• [Pain assessment: location, intensity, aggravating/relieving factors, functional impact]

Objective Re-Evaluation Findings

(Document current status with comparison to prior measurements. Include only domains relevant to current functional limitations. Omit resolved or irrelevant domains. If a clinically important domain was not assessed, briefly state the reason.)

Standardized Outcome Measures

• Tool: [Measure name] | Score/Result: [Current score with interpretation] | Conditions: [Administration conditions] | Prior → Current: [Prior score and date → Current score]
• (Add additional measures as applicable.)

Functional Performance (ADLs/IADLs)

• [Task]: [Independent / Supervision / Min A / Mod A / Max A / Dependent] due to [limiting factor(s)]; Prior → Current: [Prior status with date → Current status]
• (Add additional tasks assessed. Include relevant equipment/techniques and safety issues.)

Client Factors Driving Current Limitations

Motor

• [ROM: Joint(s) and range; Prior → Current]
• [Strength: Muscle group(s)/grade; Prior → Current]
• [Coordination/Endurance/Postural control: Findings with functional impact; Prior → Current]

Sensation/Pain

• [Somatosensation/Proprioception: Findings and functional implications; Prior → Current]
• [Pain: Location/intensity/pattern and functional impact; Prior → Current]

Vision/Perception

• [Visual acuity/oculomotor/visual fields/neglect: Findings and functional impact; Prior → Current]

Cognition/Executive Function

• [Attention/Memory/Processing speed/Executive function/Insight/Safety awareness: Findings and functional impact; Prior → Current]

Assessment

[Summary of overall change since last evaluation] (State whether improved/worsened/unchanged and anchor to key objective findings. Link objective data to occupational impact and safety.)

Progress toward active goals:

• [Goal 1]: [Met / Partially met / Not met] — [Brief objective rationale]
• (List each active goal with status.)

Prioritized problem list: (Safety and highest-impact occupations first)

1. [Problem]: [Evidence] → [Occupational impact/safety risk] → Intervention approach: [Intervention focus]
2. (Add additional problems as indicated.)

Clinical reasoning for skilled OT: [Justification for why OT expertise is required beyond routine exercise or unskilled care—specify skilled techniques, clinical decision-making, safety monitoring, and adaptation needed]

Barriers: [Medical status / pain / fatigue / cognition / psychosocial / environmental / attendance / authorization / other]

Facilitators: [Motivation / caregiver support / learning style / resources / environmental supports / other]

Prognosis: [Good / Fair / Poor] for [expected timeframe] — [Rationale based on evidence and response to date] (If progress is limited, document plausible causes and what will change in the plan.)

Updated Goals

Status of prior goals:

• [Prior Goal]: [Met / Discontinued / Modified / Continued] — [Brief rationale]
• (List each prior goal with status.)

Long-Term Goals: (Functional, measurable, time-bound; aligned with objective findings and occupational profile)

1. [Functional activity/occupation] from [Baseline status] to [Target outcome] under [Conditions] within [Timeframe].
2. (Add additional LTGs as appropriate.)

Short-Term Goals: (Map to LTGs using 1A, 1B, 2A format)

• 1A) [Sub-skill or step toward LTG 1]: from [Baseline] to [Target] under [Conditions] within [Timeframe].
• (Add additional STGs as needed to support LTGs.)

Revised Plan of Care

Frequency and duration: [Visits per week] for [Total duration/visits] (If pending authorization, state explicitly.)

Interventions: (Tied to identified problems; omit categories not applicable)

• ADL/IADL retraining and compensatory strategies: [Targets/activities]
• Therapeutic activities linked to function: [Targets/activities]
• Neuromuscular and/or cognitive strategy training: [Targets/activities]
• Splinting/orthosis: [Type/protocol/wear schedule]
• Adaptive equipment training: [Devices and training focus]
• Caregiver training and home program: [Content and frequency]
• Environmental modifications: [Recommendations]

Coordination with other providers: [Disciplines and purpose] (Omit if not applicable.)

Discharge planning: [Anticipated timeframe], [Transition plan], [Equipment needs], [Follow-up recommendations]

Treatment Rendered This Visit

(Include only if intervention was provided during the re-evaluation visit. Omit section entirely if re-evaluation only.)

• [Procedures/interventions performed with cues and adaptations]
• [Patient response/tolerance with objective indicators]
• [Immediate adjustments made based on response]

Signature

Therapist Signature/Credentials/Date: [Electronic or hand signature per policy]