The OT process begins with a referral which leads to screening and evaluation to develop an occupational profile and plan of care. Intervention is implemented which focuses on occupation and graded challenges. Reevaluation assesses progress towards goals which informs outcomes of continuing, modifying, or discharging the client. Throughout the process, documentation in a SOAP note format is required for legal, ethical, and reimbursement purposes. The dynamic OT process is client-centered and based on enabling occupation.

2. The OT Process from Start to Finish
The Evaluation Process
The Intervention Process
The Outcomes Process
Referral Screening
Occupational
Profile
Intervention
Planning
Implementation Review
Measurement
Decision
Making

3. The OT Process
Dynamic
process
Based on
OTPF
Occupation-focused

4. Referral for OT Services
TN state law does not state that we must have a
physicians referral, but insurance companies do.
Typical information addressed in an OT referral
1. Client name 6. Reason for referral
2. DOB 7. Frequency & Duration
3. Client phone number 8. Physician name
4. Primary/Medical dx 9. Date of Referral
5. Secondary/Therapy dx

5. OT Screening
Consists of quick observation and interview with
team member or family member
Request order for OT eval & tx or not
Typically ~5 minute long process
Can take place as part of the OT evaluation

6. OT Evaluation
May have limited information
Identify age, dx, and reason for referral to guide
approach
Collect and organize subjective data for the
occupational profile
Determine formatting requirements (if any)
Occupational profile includes occupational history,
occupational context, and occupational goals
Consider facility requirements of medical hx,
medications, pain scores, etc.

7. OT Evaluation Continued
Determine frequency/duration/intensity (if not
indicated on the referral form)
Determine if further evaluation is needed
Always end with signature - Betty Sue, MOTS or
MOT/S and date
Never leave anything blank

8. Essentials for Evaluation
Key things the OT should
look for in intake
information:
 Recent changes in living
environment, health
status, or occupational
performance
 Understanding setting-
specific terminology,
setting expectations, and
how to tailor to the client

9. Essentials for a Chart Review
• Procedure varies
by setting.
• Records review
may be in paper
charts, electronic
documents, etc.
Goal: to let the OT know
what to expect with regard to
potential adverse events that
might influence evaluation
and intervention.

10. Strategies for Successful Evaluations

11. Plan of Care
Consists of short- and long-term goals
Dependent on practice area
Measurable, functional, and occupation-centered
Client-centered
Time frame
Example: Sue will use an overhead method to don
and doff a t-shirt with minimal assistance in 2 of 3
trials over a one week period.

12. Intervention
PLAN
IMPLEMENT
MONITOR

13. Intervention Continued
Purposeful activities are specifically selected
activities that allow clients to develop skills that
enhance occupational performance.
Focus on collaboration for successful interventions
Start researching now! Keep a portfolio or folder full
of ideas.

14. Client-Centered

15. The Just Right Challenge
Grading - systematically
increasing the demands
of an occupation to
stimulate improved
function or reducing the
demands to respond to
the client’s difficulties in
performance.

16. Occupation as a Means and an End

17. Approaches for Intervention
Remediation or restoration
Occupational skill acquisition
Adaptation/compensation
Environmental modifications
Educational approach to improve occupational
performance
Prevention approach to “maintain”
Palliative approaches
Therapeutic use of self

18. Reevaluation
How has OT affected the client’s performance?
Re-analysis of occupational performance:
comparing initial evaluation results to new
reevaluation results; collecting data for
comparisons
Review of targeted outcomes: determine if changes
were made to occupational performance
Identify action: modify and determine needs

19. Outcomes
To continue or
discontinue … that is the
question.
Considerations: client’s
perspective, evidence,
your personal
experience, diagnostic
criteria, and intuition

20. Discharge Planning
Teamwork –
client/family input,
multi-disciplinary/trans-
disciplinary process
Consider all variables.
Anticipate, anticipate,
anticipate!
Write a discontinuation
(d/c) summary.

21. Documentation
Absolutely crucial for legal and ethical purposes
Audience: medical professionals, education
professionals, lawyers/judges/juries, accreditation
issues, payers, and the client.
Professional communication!
“If you didn’t document it, it didn’t happen!”

22. Legal and Ethical Considerations
Malpractice, fraud, negligence, and/or incompetence
Medicare and governmental payer sources
Legal documents that are part of the health records
for your client

23. Setting Requirements
Documentation is directly influenced and outlined
by the setting type
Typical elements required:
1. Date of service and/or date of completion of the
report
2. Full signature with credentials
3. Type of document (daily note, progress note, etc.)
4. Client name and case #
5. Acceptable abbreviations and terminology
6. Record storage and disposal complying with
federal/state law and facility procedures

24. Documentation
S – Subjective
O – Objective
A - Assessment: the clinicians’ interpretation of the
meaning of the “O” section
P - Plan description of what will happen next
(frequency, duration, location)
The SOAP Note

25. References
 Boyt Schell, B. A., Gillen, G., & Scaffa, M. E. (2013). Willard & Spackman’s
occupational therapy (12th ed). Baltimore, MD: Lippincott Williams & Wilkins.