Occupational Therapy Initial Evaluation
Occupational Therapy Initial Evaluation template for documenting the occupational profile, ADL/IADL baseline, skilled findings, goals, and plan of care in one place. Use it to support medical necessity, guide treatment, and create a clear start-of-care record.
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Built for: Outpatient Rehabilitation · Home Health · Skilled Nursing · Pediatrics · Acute Care
Overview
This Occupational Therapy Initial Evaluation template is built to document the first clinical assessment of a patient’s functional status, daily routines, and need for skilled OT. It organizes the occupational profile, reason for referral, medical and functional history, baseline ADL and IADL performance, objective findings, and the treatment plan into one structured form.
Use it when you need to establish medical necessity, define a baseline, and translate observations into measurable goals. The form is especially useful at the start of care, after a new injury or diagnosis, or when a patient’s function has changed enough that a fresh evaluation is needed. It helps the clinician capture what the patient can do now, what is limited, what support is available, and why occupational therapy is the right intervention.
Do not use this template as a simple checklist for routine follow-up visits. It is not meant for a quick daily note, and it should not be overloaded with unrelated history or every possible screening item. If the patient only needs a brief reassessment, a progress note or re-evaluation may be more appropriate. Keep the documentation focused on function, skilled reasoning, and the plan of care so the record is clear to the next clinician, payer reviewer, or care team member.
Standards & compliance context
- Limit collection to the minimum necessary information needed for treatment, coordination of care, and documentation of medical necessity.
- Keep the consent and disclosure section explicit when the form records PII or sensitive health information.
- Use accessibility-friendly labels, validation, and keyboard navigation so the form aligns with WCAG 2.1 AA expectations for public-facing intake.
- If the evaluation includes work-related or accommodation-related needs, document only the functional limitations needed to support reasonable accommodation decisions.
- Avoid collecting unrelated identifiers or overly broad history fields that do not support the clinical purpose of the evaluation.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Patient and Referral Information
This section identifies the patient, referral source, and service context so the evaluation is tied to the correct episode of care.
- Patient Name
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Date of Birth
Only collect if needed to confirm identity or support clinical documentation.
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Medical Record Number
Optional identifier if used by your organization.
- Referring Provider
- Evaluation Date
- Service Setting
Occupational Profile and Reason for Referral
This section explains why the patient is here and what daily life looked like before the current problem, which anchors the rest of the evaluation.
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Primary Reason for Referral
Describe the functional problem or diagnosis-related limitation prompting OT evaluation.
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Patient Goals in Their Own Words
Capture the patient’s priorities and desired outcomes.
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Prior Level of Function
Summarize baseline function before the current condition or decline.
- Living Situation
- Available Support System
Medical and Functional History
This section captures the clinical factors, precautions, pain, and cognition issues that shape what the patient can safely do.
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Relevant Medical History
Include diagnoses, surgeries, precautions, or other factors affecting occupational performance.
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Precautions or Restrictions
List any weight-bearing, movement, cognitive, or safety precautions that affect treatment.
- Is Pain Present?
- Pain Level
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Cognitive or Behavioral Factors Affecting Function
Document attention, memory, safety awareness, insight, or behavior concerns only if relevant to OT.
Baseline Occupational Performance
This section records current ADL and IADL ability so the team has a clear starting point for treatment and later comparison.
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ADL Baseline
Document baseline for bathing, dressing, toileting, grooming, feeding, and functional mobility as applicable.
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IADL Baseline
Document baseline for meal prep, housekeeping, medication management, shopping, transportation, and finances as relevant.
- Key Performance Deficits
Objective Findings and Skilled Assessment
This section translates observed impairments and environmental barriers into a skilled OT rationale that supports medical necessity.
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Upper Extremity Status
Summarize ROM, strength, coordination, tone, edema, or other relevant findings.
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Functional Cognition
Document attention, memory, sequencing, problem-solving, and safety awareness as they affect function.
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Environmental Barriers
Note home or workplace barriers, equipment needs, or accessibility concerns.
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Skilled OT Justification
Explain why the patient requires skilled OT services rather than general assistance or self-management alone.
Goals and Plan of Care
This section turns the evaluation into a treatment roadmap with measurable goals, frequency, duration, interventions, and discharge criteria.
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Short-Term Goals
Enter measurable goals with a functional outcome, target level, and timeframe.
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Long-Term Goals
Enter discharge-oriented goals that reflect meaningful occupational performance.
- Treatment Frequency
- Planned Duration (Weeks)
- Planned OT Interventions
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Discharge Plan
Describe expected discharge disposition, support needs, or follow-up recommendations.
Consent, Disclosure, and Submission
This section confirms the patient’s acknowledgment of documentation and explains what happens after the form is submitted.
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PII and Clinical Documentation Acknowledgment
Use only the minimum necessary information and follow applicable privacy requirements.
- Consent to Clinical Documentation
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Submission Notes
Optional additional comments for the therapist or reviewer.
How to use this template
- 1. Enter the patient and referral details, using the correct field type for each item and keeping identifiers limited to what is needed for the evaluation record.
- 2. Document the occupational profile by recording the referral reason, the patient’s goals in their own words, prior level of function, living situation, and support system.
- 3. Capture relevant medical history, precautions, pain, and cognitive or behavioral factors, using conditional logic so only applicable follow-up fields appear.
- 4. Record baseline ADL and IADL performance, then describe the specific performance deficits that interfere with safety, independence, or participation.
- 5. Summarize objective findings and skilled OT justification, then set measurable short-term and long-term goals with frequency, duration, interventions, and discharge criteria.
- 6. Review consent, disclosure, and submission notes before sending the form so the documentation trail is complete and the patient understands what happens after submission.
Best practices
- Use measurable language for goals, such as task, level of assistance, and target condition, so progress can be tracked without guesswork.
- Document ADL and IADL baselines separately instead of combining them into one narrative paragraph.
- Use progressive disclosure for history fields so the form does not force clinicians to review irrelevant sections for every patient.
- Tie each skilled finding to a functional consequence, such as unsafe transfers, reduced dressing independence, or poor task initiation.
- Mark required versus optional fields clearly so the form stays usable and does not collect unnecessary PII.
- Choose field types that match the data, such as date pickers for dates and numeric inputs for pain or visit counts.
- Include a clear note on what happens after submission, especially if the evaluation will be routed for review, signature, or plan-of-care approval.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
Who should use this Occupational Therapy Initial Evaluation template?
This template is for occupational therapists documenting a first visit or start-of-care evaluation. It fits outpatient, inpatient, home health, skilled nursing, and school-based settings when you need a structured record of function, barriers, and skilled OT need. It is also useful for supervisors reviewing medical necessity and plan-of-care alignment.
What does this template capture that a progress note does not?
An initial evaluation captures the occupational profile, baseline ADL and IADL performance, objective findings, and the rationale for skilled intervention. A progress note usually tracks change after treatment has started. This form is meant to establish the starting point and justify the treatment plan.
How often is this form completed?
It is typically completed once at the beginning of care, then updated only if your organization requires a re-evaluation or plan-of-care renewal. The treatment frequency and duration fields help define the expected cadence after the initial assessment. If the patient’s status changes significantly, a new evaluation or addendum may be needed.
What should be included in the skilled OT justification section?
Document the specific performance deficits, objective findings, and why clinical judgment is needed rather than a routine activity log. Tie the deficits to function, safety, or participation, and explain how OT intervention will address them. Avoid vague statements like "needs therapy" without a functional reason.
Does this template support HIPAA and minimum-necessary documentation?
Yes, if you keep the form limited to information needed for treatment, coordination of care, and billing. Use the fields to collect only relevant medical history, precautions, and functional details, and avoid unnecessary identifiers or unrelated personal data. The consent and disclosure section helps document that the patient understands what is being recorded.
How can I customize this form for different settings?
You can adjust the ADL and IADL examples, add setting-specific environmental barriers, and tailor the intervention list to your practice. Home health may emphasize safety, transfers, and caregiver support, while outpatient care may focus more on upper-extremity function and task performance. Keep the core structure intact so the evaluation still reads as a complete start-of-care record.
What are common mistakes when filling out an OT initial evaluation?
Common mistakes include leaving the baseline too vague, listing goals that are not measurable, and failing to explain why skilled OT is needed. Another frequent issue is documenting pain or cognition without connecting those findings to daily function. The form works best when each section supports the next: profile, baseline, findings, goals, and plan.
Can this template connect to other clinical workflows or systems?
Yes, it can be paired with referral intake, consent collection, scheduling, and treatment plan workflows. Many teams also link it to progress notes, reassessment forms, and discharge summaries so the evaluation becomes the source record for the episode of care. If your system supports conditional logic, you can show only the fields relevant to the service setting or diagnosis.
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