What to Expect During an OT Evaluation

Introduction to an occupational therapy evaluation

OT evaluation
Occupational Therapy Evaluation. Getty Images

Occupational therapy (OT) treatment begins with an evaluation. Your occupational therapist will likely have a set flow to the evaluation process, but knowing what to expect can help you advocate for what you want to get out of the therapy process.

Evaluations are a uniquely skilled process. They are performed by occupational therapists versus certified occupational therapy assistants. The length of evaluations can range anywhere from 20 minutes (in a setting such as a hospital) to several hours (such as in an outpatient pediatric setting.)

The field of occupational therapy is extremely diverse, and evaluation will look different in a NICU compared to a work hardening program, but overall evaluations follow this general structure.

Client Interview and Information Gathering

If a medical record is available, your occupational therapist will review it before the evaluation begins to obtain basic information about you and your medical situation. She will then interview you to fill in the gaps. Some of the straightforward information she will be looking to obtain will include the following:

  • Age
  • Referring Physician
  • Past Medical History
  • Reason for Referral
  • Diagnosis
  • Precautions

She will also seek to understand more detailed information about what your day-to-day life looked like before the incident that prompted your occupational therapy visit. Medical shorthand for this is your “Prior Level of Function (PLOF)” or “Occupational Profile.”

This information is important to understand so she can facilitate a safe discharge.

The information will also inform the goal setting process, as often the goal of OT is to return to the PLOF.

Assessments

After the interview, your therapist will perform assessments to obtain some concrete information about your general health and how your diagnosis is impacting your ability to perform everyday activities.

Your OT is trained to assess the following:

  • Pain
  • Vital Signs
  • Mental Status
  • Skin Health
  • Joint Range of Motion
  • Manual Muscle Tests
  • Level of Assistance Needs with ADLs (if any)
  • Sensation
  • Tone
  • Coordination
  • Proprioception

There are a slew of standardized assessments that your therapist may also choose to perform, ranging from sensory processing in young adults to driving safety. The specific assessments performed will depend on the setting and your particular need.

Deciding Whether You’re a Good Candidate for Therapy

Through the interview and assessment process, your OT will have identified a list of problems that she believes she can help you with. These problems should not be ones that would resolve on their own rather they must merit skilled intervention.  

It is also important that your problem merits her level of skill. For example, if a professional with less training, such as a massage therapist or exercise coach, could address your problem, your OT should refer you to them instead.

Lastly, a good candidate for therapy will exhibit the motivation for therapy and cognitive capacity to participate.

For some, the OT evaluation will be the end of their OT experience as the OT may determine further intervention is not merited.

Goal Setting 

Your occupational therapist will work with you to set goals for your OT treatment. Goals need to be measurable and relate back to the reason for your referral. Your OT will craft long-term and short-term goals.

Here is an example of a short-term goal:

Within two weeks, the client will be able to complete basic grooming while standing for 5-minute increments.

As a client, it is extremely important to know your goals. You should feel comfortable asking for a copy of your goals, as your buy-in to goals will impact the degree to which OT is successful.

Creating a Plan

After setting goals, your OT will set out a plan for achieving them. Often the plan has to be approved by a doctor. At a minimum, the plan will include how often you will benefit from therapy, how long you will benefit from OT services, and what strategies you will use to achieve the stated goals.

Here is an example of a plan:

The client will benefit from skilled OT three times per week for six weeks for therapeutic exercise and ADL training.

How Can You Be More Involved In The Evaluation Process?

As important as it is for your occupational therapist to ask you questions, it is equally important that you ask questions of her to make sure that her services are a good fit.

If there is an area of your life that you feel will impact your healing that she does not mention, be sure to bring them up. If there is something you do not understand, ask. If you think of questions beforehand or afterward, write them down. 

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