Occupational Therapy
Initial Evaluation
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No patient identifiers are stored or transmitted. All data remains on this device.
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Occupational Profile
Medical history, roles, and prior level of function
Past Medical History
Dominant Hand
Prior Level of Function (ADLs)
Living Situation
Meaningful Roles / Goals
Caregiver Availability
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Recent Hospitalization
Admission history and referral reason
Recent Hospitalization
Facility
Reason for Admission
Recent Rehab Stay (SNF/IRF)
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Pain
Current pain status at time of evaluation
Pain Scale (0–10)
Pain Location
Pain Character
Aggravating Factors
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ADL Assessment
Basic self-care performance
Notes
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IADL Assessment
Instrumental activities of daily living
Notes
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Upper Extremity Strength
Manual muscle testing — bilateral
General UE Strength
Grip Strength (Dynamometer)
Enter values to see grip strength comparison.
Fine Motor / Coordination
ROM — Upper Extremity
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Cognitive Screen
Orientation, safety awareness, and memory
Orientation
Safety Awareness
Short-Term Memory
Formal Cognitive Assessment
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Home & Safety
Fall history, home layout, and adaptive equipment needs
Falls in Previous 12 Months
Bathroom Setup
Adaptive Equipment Available
Equipment Recommended
Home Modification Recommendations
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Clinical Impressions
Goals, POC, and skilled care justification
Short-Term Goals (2–4 weeks)
Long-Term Goals (6–8 weeks)
Visit Frequency
Rehab Potential
Additional Clinical Notes
Occupational Therapy
Routine Visit Note
Patient Reports
Pain Scale (0–10)
Pain Location
Participation / Motivation
Additional Notes
ADL Performance This Visit
UE Strength / Function
MMT — Manual Muscle Testing
ROM
Interventions Performed
Adaptive Equipment Addressed
Patient / Caregiver Education Provided
Verbal Cues / Assist Level
Cognitive Carryover
Additional Notes
Progress Toward Goals
Skilled Care Justification
Rehab Potential
Additional Notes
P
Plan
Frequency, next session, and future interventions
Frequency
Next Session Focus
Planned Interventions (Next 1–2 Visits)
Goal Progression Plan
Discharge Status
Additional Notes
Occupational Therapy
Auth Request
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PATIENT SNAPSHOT
Demographics and social context
Age Range
Primary Diagnosis / Reason for OT
Recent Hospital / SNF Stay
Living Situation
Caregiver Availability
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SKILLED OT NEED & CLINICAL INDICATIONS
Primary justification for skilled services
Skilled OT Need
ADL / Functional Status
Upper Extremity / Neuromuscular
Cognitive / Safety Concerns
Safety / Fall Risk
Planned OT Interventions
Frequency
Episode Length
Short-Term Goals (4–6 weeks)
Long-Term Goals (60 days)
Rehab Potential
Payer / Insurance