How to Evaluate

After receiving a physician order for OT and after completing a chart review, the occupational therapist on the patient’s care team conducts an evaluation to determine if the patient would benefit from OT services while admitted and/ or post discharge.

The following information retrieved from Smith-Gabai, Helen, Holm, Suzanne. (2017). Occupational Therapy in Acute Care. AOTA Press.

  • Chart review 

  • Assessment measures (including skilled observations)

  • Interview and occupational profile 

  • Interpretation of findings 

  • Recommendations for intervention, consultation with other disciplines, and discharge planning. 

Typically must complete evaluation within 24 hours of receiving the referral. 

  1. Chart Review 

    1. Physician orders 

      1. Venous duplex scan: used to determine the location of a deep vein thrombosis or pulmonary embolism 

      2. CT scan: helps determine the location of a fracture, mass, or fluid retention. 

      3. MRI: detailed images of tissues and organs. 

      4. Ultrasound: provides images of tissues, organs, and blood vessels. 

      5. Laboratory values: blood and urine tests that provide important information about a patient's condition. 

    2. Patient precautions 

    3. Current and past medical history 

    4. Vital signs and medications 

    5. Laboratory and imaging reports 

    6. Progress notes

Interview and occupational profile

  1. What occupations do you NEED to do?

  2. What occupations do you WANT to do?

  3. What occupations are you EXPECTED to do?

Have clients list 5 most important occupations they wish to address. 

Client Factors 

Global and specific mental functions

  • Global: 

    • Consciousness 

    • Orientation 

    • Temperament 

    • Personality 

    • Energy and drive 

    • Sleep 

  • Specific:

    • Higher level cognition - ask “have you noticed a change in your thinking skills recently?” 

    • Attention 

    • Memory 

    • Perception

    • Thought 

    • Sequencing of complex movement 

    • Emotions 

    • Experience of self and time 

Sensory functions (for neurological patient or frail older adult)

  • Vision 

  • Hearing 

  • Touch 

  • Pain: Use a visual analogue scale (1-10). 

    • Where is the pain located?

    • What type of pain?

    • What makes the pain worse?

    • What makes the pain better? 

  • Proprioception 

    • Finger to nose 

    • Rapid alternating movements 

    • opposition

  • Vestibular function 

    • Berg balance scale 

Neuromusculoskeletal and movement related functions 

  • Muscle tone (neurological)

    • Palpate for subluxation 

  • ROM (assess during function activity)

  • Strength: MMT 

    • Contraindicated for orthopedic conditions 

Fine motor coordination/ Gross motor coordination 

  • Finger to nose 

  • Gross upper extremity dynamic reaching in multiple planes

  • Fine motor in hand manipulation (fastening buttons or snaps, tying shoes, fastening a hospital gown, twisting a bread tie, opening a tube of toothpaste).

  • Rapid alternating movements 

  • Opposition test 

  • Heel to shin test 

Motor functions and performance 

  • Tone 

    • The Modified Ashworth Scale

Static and dynamic balance

  • Sit to stand 

  • Weight shifting 

  • Posturing at the shoulder, hips, knees, and ankles. 

  • Functional reach tasks - place objects, behind, to the right and left, and in midline of the patient and then ask the patient to reach for the object. 

  • Reflexes 

  • Coordination 

  • Postural control 

  • Sensation perception

  • Memory 

  • Judgement