The occupational therapy process is the term used to describe the entire interaction between client and therapist and all steps that comprise that process as explained in the practice framework. There are three main steps to the occupational therapy process: evaluation, intervention, and outcomes. Evaluation immediately follows the initial referral for services and consists of the occupational profile–or identification of the client’s occupations–and the analysis of occupational performance–or analysis of the client’s ability to engage in those occupations. Intervention consists of intervention planning, intervention implementation, and intervention review (also called reevaluation). Outcomes focuses on the end result which may be continued services or discontinuation of services depending on the particular client.
Evaluation
Evaluation is the process of assessing a client to determine baseline performance, identify deficit areas, and develop goals for occupational therapy intervention. Occupational therapy evaluations should include a thorough assessment of a client’s occupational profile, past medical history, and performance deficits in order to allow for the development of an appropriate plan of care that is both medically necessary and client focused. Occupational therapy evaluations may also include the use of standardized assessment tools to provide a score of the client’s baseline performance and allow for consistent monitoring of progress during intervention. Current CPT codes classify occupational therapy evaluations as low, moderate, or high complexity depending upon the degree of assessment and clinical decision making necessary in the completion of the evaluation.
You can learn about assessment tools for pediatrics here and for adults here.
Intervention
Intervention is the implementation of the occupational therapy plan of care and the strategies used to bring about the desired outcomes identified in the goals. Occupational therapy interventions should be evidence based and should always maintain focus on occupations, both as a means (such as when engaging a client in a game of checkers to improve digit isolation and fine motor skills) and an end (such as when completing upper extremity exercises to facilitate increase upper body strength and increase independence in laundry tasks).
You can learn occupational therapy intervention strategies here.
Outcomes
Outcomes are measures of the result of occupational therapy intervention. They should identify how well the client met the goals identified in the initial plan of care. During a re-evaluation, an occupational therapist will identify outcomes from the initial plan of care and develop a new plan of care moving forward, whereas at discharge, an occupational therapist will identify the progress made on goals over the entire plan of care and the result of all occupational therapy interventions since the evaluation.
References and Further Reading: