Evaluation Documentation

Documentation¹ 

• Evaluation Report: documents the referral source and data gathered through the evaluation process in accordance with payer, facility, state, and federal guidelines. Includes analysis of factors that support and hinder performance and participation. Identifies areas of occupation and occupational performance to be addressed, interventions, and expected outcomes.
  • Client information, e.g., name, gender, diagnoses
  • Referral information, e.g., date and source of referral
  • Occupational profile: reason for seeking occupational therapy services,
    current areas of occupation that are successful and problematic, contexts and
    environments that support or hinder occupations, medical/educational/work
    history, occupational history (e.g., patterns of living, interest, values), client’s
    priorities, and targeted outcomes.
    • See AOTA’s Occupational Profile Template.
  • Assessments used and their results: interviews, observations, standardized, and nonstandardized assessments
  • Analysis of occupational performance: performance skills, performance patterns, contexts, environments, activity demands, and outcomes from measures.
  • Summary and analysis: interpretation and summary related to occupational profile and referring concern
  • Recommendation – professional judgment regarding the appropriateness of OT; anticipated outcomes, and frequency of therapy. The recommendation is described in the intervention plan.
• Revaluation Report (if required): contains updated information from the evaluation and any changes made such as client progress, frequency, and needs of the setting to the intervention/discharge plan.

1. Clark, G. F., & Youngstrom, M. J. (2008). Guidelines for documentation of occupational therapy. The American Journal of Occupational Therapy, 62(6), 684.[↩]