Evaluation & assessment
The evaluation process is focused on finding out what the client wants and needs to do; determining what the client can do and has done; and identifying supports and barriers to health, well-being, and participation. Evaluation occurs during the initial and all subsequent interactions with a client. The type and focus of the evaluation differ depending on the practice setting; however, all evaluations should assess the complex and multifaceted needs of each client.
Essential components of an occupational therapy evaluation include:
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Occupational profile: Summary of the client’s occupational history and experiences, patterns of daily living, interests, values, needs, and relevant contexts.
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Analysis of occupational performance: The step in the evaluation process in which the client’s assets and limitations or potential problems are specifically determined through assessment tools designed to analyze, measure, and inquire about factors that support or hinder occupational performance.
The occupational therapy intervention plan is developed after careful review and synthesis of information from the client's occupational profile and the occupational therapist's analysis of the client's occupational performance.
AOTA evaluation checklists
Use the AOTA Evaluation & Quality Measures Checklists during evaluations as a reminder of items to evaluate and address. AOTA encourages practitioners to use the checklists to help guide client evaluations, as well share with colleagues to provide information about the occupational therapy evaluation process. The checklist supports high-quality, high-value occupational therapy evaluations that lead to occupation-based, client-centered interventions.
- Home Health Evaluation Checklist & Quality Measures
- Medicare Part B Evaluation Checklist & Quality Measures
- Skilled Nursing Evaluation Checklist & Quality Measures
- Acute Care Evaluation Checklist & Quality Measures
- OT Pediatric Evaluation Checklist
Section GG template
Section GG outcome measures are utilized in all post-acute care (PAC) settings for Medicare beneficiaries to track progress across the continuum of care.
Section GG - Medicare Self-Care and Mobility Measures
Reference
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001