OT Assessment Template

Occupational Therapy Assessment Template 1. Patient Information Name: [patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Date of Birth: [patient's date of birth] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) NHS / Hospital Number: [patient's NHS or hospital number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Address / Contact: [patient's full address and contact information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Date of Assessment: [the date the assessment was conducted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Assessor: [name and professional title of the assessor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Location (ward/community): [location of the assessment, e.g., ward name, community setting] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) --- 2. Referral Details Reason for Referral: [detailed reason for the occupational therapy referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Date of Referral: [date the referral was made] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Referrer (name & role): [name and professional role of the individual who made the referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Background Summary: [summary of the patient's relevant background information leading to the referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) --- 3. Medical & Social History Primary Diagnosis: [patient's primary medical diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Relevant Medical History: [summary of relevant past and current medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Surgical History (if applicable): [details of any past surgical procedures relevant to the current condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Medications: [list of all current medications, including dosage and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Social History: [detailed description of the patient's social context] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in paragraphs of full sentences.) Living situation: [patient's current living arrangements and household composition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Support network: [description of the patient's available support system from family, friends, or caregivers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Employment / occupation: [patient's current or past employment status and type of occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Hobbies / interests: [patient's leisure activities and personal interests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) --- 4. Functional Assessment Personal care (washing, dressing): [checkbox indicating independence, assistance, or inability for personal care tasks] [any additional comments regarding personal care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) Toileting: [checkbox indicating independence, assistance, or inability for toileting] [any additional comments regarding toileting] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) Mobility: [checkbox indicating independence, assistance, or inability for mobility] [any additional comments regarding mobility] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) Transfers (bed, chair, toilet): [checkbox indicating independence, assistance, or inability for transfers] [any additional comments regarding transfers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) Meal preparation / feeding: [checkbox indicating independence, assistance, or inability for meal preparation and feeding] [any additional comments regarding meal preparation and feeding] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) Domestic tasks: [checkbox indicating independence, assistance, or inability for domestic tasks] [any additional comments regarding domestic tasks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) Community access: [checkbox indicating independence, assistance, or inability for community access] [any additional comments regarding community access] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) Communication: [checkbox indicating independence, assistance, or inability for communication] [any additional comments regarding communication] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) --- 5. Cognitive / Perceptual Assessment Orientation (time/place/person): [assessment findings regarding orientation to time, place, and person] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Attention / Concentration: [assessment findings regarding attention span and concentration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Memory: [assessment findings regarding short-term and long-term memory] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Problem-solving: [assessment findings regarding problem-solving ability] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Insight / Awareness: [assessment findings regarding insight and self-awareness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Perceptual difficulties (e.g., visual neglect, apraxia): [assessment findings with examples] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) --- 6. Physical Assessment Upper limb function: [assessment findings regarding upper limb strength, range of motion, and coordination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Grip strength / fine motor control: [assessment findings regarding grip strength and fine motor skills] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Balance / postural control: [assessment findings regarding balance and posture] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Endurance / fatigue: [assessment findings regarding endurance and fatigue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Pain: [description of any pain, including location, intensity, and impact] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Sensory issues: [description of any sensory deficits or hypersensitivity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) --- 7. Environmental Assessment (if applicable) Access to property (steps, ramp, lift): [details of accessibility features or barriers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Layout / safety concerns: [description of property layout and safety concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Equipment in situ: [list of existing equipment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Recommendations: [recommendations for environmental modifications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) --- 8. Patient Goals Goal 1: [patient's first stated goal for occupational therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Goal 2: [patient's second stated goal for occupational therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Goal 3: [patient's third stated goal for occupational therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) --- 9. OT Recommendations / Plan Equipment provision: [recommendations for specific equipment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Adaptations required: [details of necessary environmental or task adaptations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Therapy input / interventions: [proposed occupational therapy interventions and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Education provided: [details of any education or advice given] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Referrals made (e.g., physio, social services, falls team): [list of onward referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) --- 10. Summary / Clinical Impression [summary of the assessment findings, impact on function, and discharge planning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in paragraphs of full sentences.) --- 11. Action Plan / Follow-Up Next review date: [scheduled date for next review] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Planned sessions: [number and type of planned sessions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) Discharge / onward referral details: [details regarding discharge or referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in a single line.) (For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that it was not mentioned; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)