INITIAL OCCUPATIONAL THERAPY EVALUATION AND CARE PLAN 2026

1. Click ‘Get Form’ to open the INITIAL OCCUPATIONAL THERAPY EVALUATION AND CARE PLAN in the editor.
2. Begin by entering the patient's name, date, and time in the designated fields at the top of the form. Ensure accuracy for proper documentation.
3. Fill in the agency name and patient’s date of birth, selecting gender as applicable. This information is crucial for identifying patient records.
4. In the 'Significant Medical History/Clinical Findings' section, provide details about primary diagnosis and onset date. Include past medical history and prior OT services received.
5. Complete the 'Weight Bearing Status' and 'Precautions' sections to inform therapists about any limitations or special considerations.
6. Assess mental status, vitals, pain levels, living situation, and any durable medical equipment used by filling out each respective field thoroughly.
7. For functional assessments, indicate current and prior functional statuses using the provided scales for various activities. This helps track progress over time.
8. Document planned interventions based on assessment findings. Choose from options like self-care retraining or adaptive equipment training as needed.
9. Finally, ensure that all signatures are collected where required before saving or sharing your completed evaluation plan.

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