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Occupational Therapy Evaluation Guide

Jul 1, 2025

Overview

This video provides a step-by-step guide for occupational therapists on evaluating adult or geriatric patients, building occupational profiles, setting therapy goals, and conducting assessments in clinical settings.

Building the Occupational Profile

  • Begin by gathering background information about the patient, such as identity, daily roles, interests, and meaningful activities.
  • Review the patient’s chart for medical diagnoses, surgeries, and relevant medical history.
  • Ask direct questions about driving, lifestyle, current and past conditions to form a holistic understanding.
  • Identify any precautions or special considerations from the patient’s health status.

Identifying the Patient’s Main Challenges

  • Ask patients what activities they are struggling with or unable to do now compared to before.
  • Use specific follow-up questions to pinpoint the root causes of difficulties (e.g., physical weakness, environmental barriers).
  • Clarify if patients are aware of their limitations and whether they perceive them as problems.

Gathering Additional Information

  • If patients have cognitive impairments or cannot express their difficulties, consult with caregivers, family members, or power of attorney.
  • Contact family to determine the patient’s prior level of function (PLOF) before illness or injury.

Assessment and Functional Evaluation

  • Conduct a thorough assessment including biomechanics, strength, range of motion, and functional self-care tasks.
  • Observe the patient performing daily activities and transfers to determine safety and ability.
  • Assess both physical and cognitive abilities simultaneously to ensure safety and personalized intervention.

Goal Setting with the Patient

  • Directly ask patients about their personal therapy goals when possible.
  • Incorporate the patient’s desired outcomes into goal creation for therapy.
  • If unable to assess certain activities initially, document and plan to address in future sessions.

Recommendations / Advice

  • Use all gathered information to tailor interventions and track progress towards returning the patient to desired activities.
  • Adjust goals and plans based on ongoing assessments and patient input.

Questions / Follow-Ups

  • Consider creating additional content on therapy interventions or addressing specific viewer questions in future videos.
  • Solicit feedback and ideas for future topics from viewers.

Action Items

  • TBD – Viewers: Provide feedback or questions for future video topics.
  • TBD – Therapist: Follow up on unassessed areas in future sessions for a complete evaluation.