Effective occupational therapy (OT) evaluations are essential for developing client-centered interventions that enhance client outcomes. As a core part of these evaluations, assessment tools help occupational therapy practitioners (OTPs) gather vital information about each client’s strengths, needs, and goals. This guide offers practical strategies and resources to support practitioners in conducting comprehensive evaluations, ensuring a thorough understanding of each client's unique needs and guiding client-centered care.
Conducting an OT Evaluation
One essential resource for OTPs is The Occupational Therapy Practice Framework: Domain and Process (OTPF-4). This document provides an overview of OT practice for practitioners, students, and educators. It is an evolving document that is updated every five years as practice trends evolve. OTPs are encouraged to periodically consult the OTPF-4 to ensure their evaluations reflect best practices in occupational therapy.
The Evaluation section of the OTPF-4 provides the following description of the purpose of an OT evaluation: “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.”
AOTA Checklists
AOTA offers several valuable resources, including comprehensive evaluation checklists tailored to specific practice areas. All are based on OTPF-4.
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OT Skilled Nursing Facility Evaluation Checklist & Quality Measures provides guidance for occupation-based, client-centered interventions when a client is in a skilled nursing facility and focuses on Medicare quality measures.
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The OT Medicare Part B Evaluation Checklist and Quality Measures is designed for outpatient Medicare Part B occupational therapy evaluations.
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Home Health Evaluation Checklist and Quality Measures provides guidance for evaluating Medicare clients receiving home health services.
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The OT Pediatric Evaluation Checklist considers factors that are important when providing OT services to young people.
At the core of every OT evaluation is the occupational profile, a foundational tool that helps ensure the client’s perspective remains central throughout the therapy process.
Using the AOTA Occupational Profile Template
The AOTA Occupational Profile Template is based on the OTPF-4 and is used to guide a conversation between practitioner and client. Completing an occupational therapy profile is a requirement for every OT evaluation.
As you work with your client, you’ll explore factors that support or inhibit their engagement in meaningful activities. Areas addressed include:
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Reasons for seeking OT
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Occupational history
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Personal values, interests, and contexts
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Performance patterns, body functions, and structures
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Client priorities and outcomes
This process allows you to collaborate with your client to create a plan that improves their participation in meaningful activities.
Assessment Tools
Assessments play a crucial role in helping occupational therapy practitioners (OTPs) understand and address their clients’ needs. These assessments provide information to the practitioner to inform the creation of individualized treatment plans. As an OTP, it’s important to explore your client’s strengths, challenges, and goals: What activities are they involved in? What barriers or supports exist? With a wide range of assessment tools available, selecting the right one ensures personalized, effective care.
One essential resource for this process is AOTA’s Quality Toolkit. This toolkit provides an overview of commonly utilized assessments covering key domains (including but not limited to):
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Activities of Daily Living (ADLs): Assesses essential self-care tasks such as dressing, bathing, and feeding.
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Instrumental Activities of Daily Living (IADLs): Evaluates more complex life skills like meal preparation, managing finances, and community navigation.
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Functional Cognition: Includes tools for assessing memory, problem-solving, and multitasking, such as the Cognition Screening, Multiple Errands Test, and Weekly Calendar Planning Activity.
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Social Participation and Interaction: Focuses on interpersonal skills vital for community engagement and social integration.
By using these tools, OTPs can develop a comprehensive understanding of a client’s abilities across multiple domains, informing tailored interventions that enhance participation and well-being.
Assessing Mental and Behavioral Health
Mental and behavioral health are key to full occupational participation. OTPs use some of the following assessments to learn how mental and behavioral health challenges such as depression, anxiety, and low self-esteem may be affecting clients.
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Brief-Coping with Problems Experienced includes 14 scales that assess someone’s coping strategies.
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The General Self-Efficacy Scale (GSE) is a scale designed to measure someone’s beliefs that their actions are responsible for outcomes.
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The Geriatric Depression Scale measures depression and suicidal ideation in elderly individuals.
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Generalized Anxiety Disorder 7-item (GAD-7) is a quick screening tool used to measure the severity of generalized anxiety disorder symptoms, helping clinicians identify and monitor anxiety.
- Generalized Anxiety Disorder 7-item (GAD-7) Psychometrics provides the reliability and validity of the GAD-7 tool, confirming its effectiveness in assessing anxiety levels and symptoms.
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Interest Checklist/Role Checklist (MOHO) Version 3 assesses an individual’s interests and roles in daily activities, providing insights into occupational performance and participation through the Model of Human Occupation (MOHO) framework.
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Patient Health Questionnaire (PHQ-9) is a brief checklist that assesses the presence and intensity of depressive symptoms.
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Rosenberg’s Self-Esteem Scale is a measure of someone’s feelings about their self-esteem.
These assessments can provide OTPs with insights to tailor interventions, fostering mental well-being and enhanced participation in meaningful activities.
The Importance of Rest and Sleep
Quality sleep and rest habits are critical components of a client's overall health and ability to participate in daily activities. Several assessment tools are available, such as:
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Functional Outcomes of Sleep Questionnaire (FOSQ) assesses the impact of sleep disorders on daily activities.
- Functional Outcomes of Sleep Questionnaire (FOSQ) Psychometrics
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Pittsburgh Sleep Quality Index, which is a widely used measure that evaluates sleep disturbances and overall sleep quality.
Addressing Sensory Integration and Processing
When OTPs identify possible challenges in clients’ ability to process and integrate stimuli, the following tools may be useful.
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Evaluation in Ayres Sensory Integration provides reliability and validity data for the EASI, giving OTPs confidence in its accuracy for assessing sensory integration and motor skills in children.
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Participation and Sensory Environment Questionnaire (PSEQ) tool assesses how sensory processing impacts participation across environments like home and school, helping OTPs understand and adjust for sensory-related challenges.
- Participation and Sensory Environment Questionnaire Psychometrics: Offers psychometric data on the PSEQ, supporting its use for evaluating sensory processing in diverse settings.
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Structured Observations of Sensory Integration-Motor Tool (SOSI-M) is a hands-on tool that guides OTPs in observing motor and sensory integration in real-time, aiding in identifying sensory-motor challenges.
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The Sensory Processing Measure, Second Edition (SPM-2), evaluates sensory processing across multiple settings, highlighting how sensory challenges affect functional performance.
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The Sensory Profile 2 focuses on measuring a child's sensory processing patterns and how these patterns influence participation in everyday life activities across different contexts.
- Sensory Profile 2 Psychometrics provides data on the reliability and validity of the Sensory Profile 2, supporting OTPs in confidently using this tool to assess sensory processing patterns.
Targeted Evaluations for Better Outcomes
Effective OT evaluations are key to delivering personalized, client-centered care. By utilizing the AOTA Occupational Profile Template and a variety of specialized assessments, OTPs can gain a holistic understanding of their clients' strengths and challenges.
Incorporating these resources into practice allows OTPs to provide high-quality care, which can lead to improved outcomes and increased participation in meaningful activities.
Note that AOTA does not specifically endorse any of the external resources noted. These are not all-inclusive lists of occupational therapy evaluations. The practitioner should use their clinical judgment to identify tools and resources appropriate for each client based on the client, the situation, and the psychometrics of the instruments.
