Occupational Therapy Initial Evaluation Checklist

Comprehensive occupational therapy evaluation including ADL assessment, cognitive screening, and individualized treatment planning.

  • Industry: Healthcare
  • Frequency: Initial evaluation
  • Estimated Time: 45-60 minutes
  • Role: Occupational Therapist
  • Total Items: 31
  • Compliance: AOTA Practice Framework, CMS Documentation Requirements, State Practice Act

Occupational Profile

Patient history and goals

  • Prior level of function documented?
  • Living situation documented?
  • Occupational roles identified?
  • Patient/caregiver goals identified?

Performance Skills

Skills assessment

  • Motor skills assessed?
  • Process/cognitive skills assessed?
  • Sensory function assessed?

ADL Assessment

Activities of daily living

  • Basic ADLs assessed (bathing, dressing, feeding)?
  • IADLs assessed (cooking, cleaning, money)?
  • Safety with ADLs assessed?

Treatment Plan

Intervention planning

  • Measurable goals established?
  • Interventions planned?
  • Frequency and duration specified?

Pre-Assessment Information

Initial assessment documentation and patient/facility identification

  • Assessor Name / Credentials
  • Assessment Date
  • Department / Unit
  • Assessment Type (Routine/Annual/Complaint)
  • Previous assessment findings reviewed?

Infection Prevention & Control

Verify infection control practices per CDC and Joint Commission standards

  • Hand hygiene compliance observed?
  • Appropriate PPE available and properly used?
  • Isolation precautions properly implemented?
  • Sharps containers available and not overfilled?
  • High-touch surfaces properly disinfected?

Patient Safety & Identification

Verify patient safety protocols and identification procedures

  • Two patient identifiers used before procedures?
  • Fall risk assessment completed?
  • Call light within patient reach?
  • Bed in lowest position with brakes locked?

Medication Safety & Management

Verify medication handling and administration practices

  • Medications stored securely and at proper temperature?
  • Controlled substances properly secured and counted?
  • No expired medications in stock?
  • High-alert medications properly labeled?

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Why Use This Occupational Therapy Initial Evaluation Checklist?

This occupational therapy initial evaluation checklist helps healthcare teams maintain compliance and operational excellence. Designed for occupational therapist professionals, this checklist covers 31 critical inspection points across 8 sections. Recommended frequency: initial evaluation.

Ensures compliance with AOTA Practice Framework, CMS Documentation Requirements, State Practice Act. Regulatory-aligned for audit readiness and inspection documentation.

Frequently Asked Questions

What does the Occupational Therapy Initial Evaluation Checklist cover?

This checklist covers 31 inspection items across 8 sections: Occupational Profile, Performance Skills, ADL Assessment, Treatment Plan, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management. It is designed for healthcare operations and compliance.

How often should this checklist be completed?

This checklist should be completed initial evaluation. Each completion takes approximately 45-60 minutes.

Who should use this Occupational Therapy Initial Evaluation Checklist?

This checklist is designed for Occupational Therapist professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.

Can I download this checklist as a PDF?

Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.

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