Documenting an Evaluation: Tips & Examples in the Acute Setting
Looking for comprehensive acute care occupational therapy resources — documentation tips, treatment planning, evaluation assessments, and more? The Acute Care Essentials Toolkit was created to support confident, efficient documentation and streamlined care planning. Learn more about what’s included and how it can help your acute care practice by clicking here!
When documenting an initial occupational therapy evaluation in the acute care setting, there are several key factors that must be considered for nearly every patient, regardless of diagnosis or mechanism of injury. The sections outlined below represent the most common components of an OT evaluation in acute care.
I created this free resource to provide practical documentation examples that can be used as a cheat sheet while you develop your own documentation style. Trust me—documentation does become second nature with time, but early on it can feel overwhelming and time-consuming.
My primary goals when documenting an initial evaluation are to:
Clearly describe how the patient’s current functional status compares to their prior level of function.
Accurately capture how the patient presented during the evaluation, including vitals response, reported symptoms, and level of assistance required.
Identify barriers to a safe discharge and justify the most appropriate next level of care, whether that is returning home, short-term rehabilitation, long-term care, or continued hospitalization.
The most common elements I make sure to assess and then document in the electrical medical record (EMR) include: (I include documentation examples below)
Prior Level of Function (PLOF) - Was the patient independent with BADLs, IADLs, and ambulation? or did they require assistance completing BADLs?
Home environment - Identify any barriers to safety or independence
Precautions - Does the patient have contact precautions? Bedrest orders?
Activity tolerance - Can the patient tolerate 10-20 minutes of activity without shortness of breath?
History of present illness - COPD, A-fib, CVA (all important to know)
Pain - 1-10 scale rating pre/post mobility
General appearance - E.g., IV, foley, nasal cannula
Vision basic screening - Important to assess for stroke
Vision complex assessment - Saccades, pursuits, convergence
Speech / hearing assessment - Do they have clear speech? Do they wear a hearing aide?
Cognition - Ask patient person, place, time, situation questions
Perception - Assess motor planning, e.g., finger to nose test
ADL - Lower body dressing, upper body dressing (functional UE assessment), toileting, grooming at sink
Bed mobility - Rolling, supine > seated edge of bed (EOB), EOB > supine
Transfers - Sit to stand, stand to sit, stand pivot transfer
Balance - Static sitting balance, dynamic sitting balance, static standing balance, dynamic sitting balance- do they require unilateral or bilateral upper extremity assist?
RUE assessment/ LUE assessment
Coordination - Important to assess for stroke patients
Hand function - Are they able to sustain grasp on utensils or cup when eating meals?
Sensation - Important to assess for stroke patients
Skin assessment - Does the patient have skin breakdown from prolonged bed rest?
Treatment preformed - What treatment did you complete? e.g., education on WB precautions, bed mobility, grooming at sink.
ADL goals - What are the patient’s main goals for therapy? Which ADLs do they require assistance with?
Education - What did you educate the patient/ family on during the evaluation?
Recommendation - Where is the safest place to discharge where the patient can be the most independent?
Prioritization information - do they require PT/OT co-treat due to being max Ax2 for bed mobility or ADLs?
The next section includes three of my favorite documentation examples for each section listed above:
Prior Level of Function (PLOF)
Patient is independent with all ADLs/IADLs and functional mobility without assistive device prior to admission
Patient required intermittent assistance for bathing and lower body dressing at baseline
Patient lived independently with no history of falls prior to admission
Home Environment
Lives in single-story home with 3 steps to enter and bilateral handrails
Lives alone in apartment with elevator access and walk-in shower
Lives with spouse in two-story home; bedroom and bathroom located on second floor
Precautions
Fall precautions in place
Weight-bearing as tolerated (WBAT) RLE per orthopedic orders
Monitor oxygen saturation and blood pressure during activity
Contact precautions
Activity Tolerance
Tolerated 10 minutes of activity with multiple rest breaks
Demonstrated fair activity tolerance limited by fatigue and SOB
Activity tolerance limited by orthostatic hypotension
History of Present Illness (HPI)
Admitted for acute ischemic CVA with R-sided weakness
Presented with generalized weakness and decreased endurance following prolonged hospitalization
Admitted s/p fall resulting in L hip fracture and surgical repair
Pain
Reports 6/10 pain in R shoulder with movement
Denies pain at rest; increased discomfort noted with activity
Pain managed with repositioning and rest breaks during session
Tip: Always report pain to nurse post session!
General Appearance
Patient alert, resting in bed, no acute distress noted
Appears fatigued with limited eye contact during evaluation
Patient seated upright in bed with IV, telemetry, and O2 in place
Vision – Basic Screening
Able to track objects in all quadrants
Wears corrective lenses; reports vision at baseline
Demonstrates difficulty with visual tracking to L side
Vision – Complex Assessment
Demonstrates decreased visual scanning to L consistent with neglect
Impaired visual perception impacting safety during mobility
Difficulty with figure-ground discrimination during functional tasks
Speech / Hearing Assessment
Speech clear and intelligible; able to follow commands
Mild expressive aphasia noted; SLP consulted
Hearing WFL; responds appropriately to verbal cues
Cognition
Alert and oriented x4 (person, place, time, and situation)
Requires increased time and repetition to follow multi-step commands
Demonstrates impaired short-term memory affecting task carryover
Perception
Demonstrates L inattention impacting ADL performance
Body awareness impaired during functional mobility
Perceptual deficits impacting safety awareness
ADLs
Requires mod A for upper body dressing due to decreased UE strength
Requires max A for lower body dressing due to decreased activity tolerance
Grooming completed seated with setup assistance with stable vital signs
Bed Mobility
Patient completed supine to sit edge of bed (EOB) with min A using bed rail
Rolling performed with verbal cues only
Requires mod A for repositioning in bed
Required verbal cues to reach and place hand on bed rail and scoot hips toward EOB
Transfers
Sit-to-stand transfer completed with min A and RW
Toilet transfer completed with mod A and grab bar
Stand pivot transfer requires max A for safety
Balance
Static sitting balance: supervision, did not require bilateral use of upper extremities to maintain sitting balance
Dynamic standing balance: contact guard assist (CGA), required bilateral upper extremity support to maintain standing balance
Balance deficits noted impacting safety during ADLs
Right Upper Extremity (RUE) Assessment
RUE strength grossly 3+/5
Limited AROM in shoulder flexion due to pain
RUE edema noted distally
Left Upper Extremity (LUE) Assessment
LUE strength WFL
Full AROM noted throughout LUE
LUE functional use intact during ADLs
Coordination
Decreased fine motor coordination noted during grooming
Difficulty with bilateral coordination tasks
Movements slowed but accurate - most notable with stroke and Parkinson’s disease
Hand Function
Decreased grip strength impacting sustained grasp holding cup
Range of motion (ROM) and strength within functional limits (WFL) for activities of daily living (ADLs)
Difficulty manipulating small objects
Sensation
Reports numbness to partial sensation deficits of left upper extremity
Light touch diminished distally
Sensation intact to gross touch
Skin Assessment
Skin intact with no breakdown noted
Redness noted to sacral area; nursing notified
Increased risk for skin breakdown due to limited mobility
Treatment Performed
OT evaluation
ADL training initiated focusing on grooming and dressing
Education provided regarding energy conservation
ADL Goals
Patient will complete AM ADL routine (e.g., grooming standing at sink, UE/LE dressing, and toileting) with no more than supervision and stable vital signs prior to discharge.
Patient will complete toileting (peri-care and clothing mgmt) with no more than supervision prior to discharge.
Patient will tolerate grooming task standing at the sink > 5 minutes with stable vital signs prior to discharge.
Education
Education provided on safety during mobility
Instructed patient on use of call bell
Education provided to patient and family regarding discharge planning
Assessment (Summary)
Patient (first/last name) is a ___ yo male/female referred to skilled OT services to address functional deficits related to (diagnosis). Patient has a past medical history of ___. At baseline, pt is (independent) with ADLs, (mod I) with functional mobility (uses RW), and lives with (spouse). Patient presented with (decreased activity tolerance, generalized muscle weakness, pain) manifesting as performance deficits with (standing ADLs, bed mobility, transfers, and functional mobility). Pt requires (assist level) for standing ADLs and (assist level) for functional mobility/ transfers. At this time, (patient would benefit from continued skilled OT to prevent further decline and increase safety and functional independence with ADLs and functional mobility/ patient does not require additional acute skilled OT and is safe to discharge home when medically stable). Recommend (home independently/ caregiver assist/ post acute stay).
Plan
Continue OT services 3–5x/week
Focus on ADL retraining, functional mobility, and endurance
Reassess discharge needs as patient progresses
Recommendations
Recommend discharge to inpatient rehabilitation
Recommend home with home health OT
Recommend continued OT services in acute care
Evaluation / Treatment Time
OT evaluation: 25 minutes
Therapeutic activity: 15 minutes
Total OT time: 40 minutes
Prioritization Information
Patient prioritized due to new CVA and discharge planning needs
Requires 2 person assist (co-treat with PT)
Priority evaluation due to functional decline from baseline
Disclaimer: This information is intended as a clinical guide and should be adapted to facility-specific documentation standards and patient presentation.
Looking for more documentation examples, treatment planning, evaluation tips, and more acute care OT resources? The Acute Care Essentials Toolkit was created to support confident, efficient documentation. Click here to learn more!