Occupational therapy (OT) helps people across the lifespan participate in activities they want and need to do through the therapeutic use of everyday tasks. When physical, cognitive, or emotional barriers limit a person’s ability to engage in daily life, an occupational therapist promotes health and well-being. The foundational first step is the occupational therapy evaluation, a comprehensive assessment of a person’s current abilities and challenges. This initial evaluation forms the basis for all future intervention and is a prerequisite for developing a personalized treatment plan.
Defining Occupational Performance and Client Goals
The OT evaluation centers on the client’s “occupational performance,” which is the ability to engage in activities that give life meaning. These activities, or “occupations,” include self-care, work, leisure, education, and social participation. The evaluation identifies what the person wants and needs to do, and the factors that support or hinder that participation.
The therapist works collaboratively with the client to identify specific, relevant issues, ensuring the process is client-centered. For example, the evaluation explores how an injury affects the ability to dress independently or how a cognitive impairment impacts managing a household budget. This approach allows the therapist to target interventions that align with the person’s values, roles, and desired outcomes.
The evaluation identifies the client’s strengths and resources alongside their limitations. This holistic view considers the person’s physical, emotional, and cognitive functions, as well as their environmental and social context. Understanding the client’s narrative and perception of their performance helps the therapist establish a baseline and negotiate achievable, targeted outcomes.
The Three Main Steps of the Evaluation Process
The evaluation appointment is a multi-faceted process designed to gather comprehensive data, typically following three distinct procedures. The first step is the Initial Interview, where the therapist gathers the client’s history and establishes rapport. This conversation covers medical history, daily routines, social context, and the client’s perceived barriers to desired activities.
The therapist uses this discussion to begin constructing the “occupational profile,” a summary of the client’s past experiences, daily living patterns, interests, and needs. This profile contextualizes the client’s current problems, helping the therapist understand the client’s life roles and environments. The interview is also where the client articulates specific goals for therapy, forming the foundation of the treatment plan.
The second step involves Clinical Observations, where the therapist watches the client perform specific, meaningful tasks. This observation is often performed in the client’s natural or a simulated environment, providing a realistic view of performance. The therapist analyzes the quality of the client’s motor, process, and social interaction skills while they complete a task, such as preparing a meal.
The final procedure is the use of Standardized Assessments, which are formal tools used to objectively measure skills. These tests provide baseline data and measure areas like fine motor coordination, cognitive function (memory and planning), or independence in self-care tasks. Examples include performance-based tests or questionnaires that help the therapist quantify the client’s abilities and monitor progress throughout the intervention.
Translating Findings into an Intervention Plan
Following the evaluation, the therapist synthesizes all gathered information to formally document the findings. This results in the final Occupational Profile, a detailed written summary of the client’s performance capacity, environment, and challenges they face. This profile identifies specific factors that support or interfere with the client’s engagement in daily occupations.
The data collected from the interview, observations, and standardized tests is used to create a measurable Intervention Plan. This plan details the specific therapeutic strategies and establishes measurable short-term and long-term goals. Long-term goals focus on the ultimate return to a desired occupation, while short-term objectives outline the incremental steps needed to achieve that larger goal.
Goals are written to be Specific, Measurable, Achievable, Relevant, and Time-bound (SMART), ensuring they are practical and focused on the client’s priorities. The Intervention Plan guides subsequent treatment sessions, transitioning the client from assessment to active rehabilitation. The evaluation findings ensure the entire course of therapy remains focused on enabling the client to participate fully in meaningful activities.