What Happens During an OT Evaluation?

An occupational therapy (OT) evaluation includes an in-person assessment and a formal written report. The occupational therapist will:

• Ask about the client’s pre-injury function and how they engaged in daily activities before any decline or injury.
  
  

• Observe the client performing functional tasks, often in their natural environment, and may use standardized or nonstandardized assessments to support clinical reasoning.
  
  

• Identify barriers and supports that impact the client’s participation in daily life, such as physical, cognitive, emotional, environmental, or social factors.
  
  

• Create a treatment plan with specific, measurable goals, tailored interventions, and appropriate referrals to other healthcare services if needed.
  
  

• Write a formal report summarizing findings, measurable goals, and professional recommendations for insurers, healthcare providers, or interdisciplinary teams.
  
  

What Are Examples of Different OT Assessment Types?

• Hospital Discharge Planning
  Does the client need adaptive equipment, home modifications, or support services to return home safely?
  
  

• Cognitive Rehabilitation
  Has the client experienced changes in memory, attention, or executive functioning after a concussion, brain injury, or mental health condition?
  
  

• Ergonomic Assessment
  Is the client experiencing pain or discomfort at work related to poor desk setup, posture, or workstation ergonomics?
  
  

• Return-to-Work Planning
  Does the client need a structured, step-by-step plan to return to work safely? Can job tasks or roles be modified to support their reintegration?
  
  

Where Does the OT Evaluation Take Place?

OT evaluations can occur in various settings, depending on the client's needs and context, including:

• The client's home (home safety evaluations)
  
  

• Workplaces (ergonomic assessments, return-to-work planning)
  
  

• Community settings (grocery stores, community centers)
  
  

• Healthcare settings (acute care hospitals, rehabilitation centers, outpatient clinics)
  
  

Many occupational therapists work in vivo, meaning they observe and assess clients in their natural, everyday environments to gather the most accurate and relevant information.

What Is the Result of the Evaluation?

After the evaluation, the occupational therapist will produce a formal written report that typically includes:

• Observations and clinical findings based on direct assessment and client/caregiver input
  
  

• Recommendations for adaptive equipment, services, home modifications, therapy needs, or referrals
  
  

• Client-centered goals focused on functional recovery, participation, and improved quality of life
  
  

• Treatment recommendations, if medically appropriate, outlining the need for ongoing therapy, education, or environmental supports
  
  

The report is used to guide therapy interventions and may also be shared with insurers, case managers, physicians, or other interdisciplinary professionals to coordinate care.

References

OT Works! (2019, September 23). OT initial assessment. https://www.ot-works.com/2019/09/ot-initial-assessment/