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?
Related Healthcare Checklists
- Hand Hygiene Compliance
- Medication Safety Check
- Surgical Safety Checklist
- Fall Prevention Assessment
- Joint Commission Readiness
- HIPAA Compliance Audit