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Improve Your Documentation With AOTA's Occupational Profile Template

The Occupational Therapy Practice Framework: Domain and Process (3rd ed., American Occupational Therapy Association [AOTA], 2014) states that every occupational therapy evaluation includes (1) the occupational profile and (2) the analysis of occupational performance. As the first step in the evaluation process,

the occupational profile provides...an understanding of a client’s perspective and background...During the process of collecting this information, the client, with the assistance of the occupational therapy practitioner, identifies priorities and desired targeted outcomes that will lead to the client’s engagement in occupations that support participation in life. Only clients can identify the occupations that give meaning to their lives and select the goals and priorities that are important to them. By valuing and respecting clients’ input, practitioners...can more efficiently guide interventions. (AOTA, 2014, p. S13, italics added)

Consistently conducting and documenting the occupational profile is the first step in improving the quality of occupational therapy services and demonstrating the profession’s distinct value to other health care providers, reviewers, and payers. The profile demonstrates occupational therapy practitioners’ commitment to clients as collaborators in the occupational therapy process and facilitates client-centered practice. In addition, the 2017 occupational therapy evaluation and re-evaluation CPT® codes require the inclusion of an occupational profile (get more information on the new evaluation codes).

To assist occupational therapy practitioners in conducting an occupational profile with each client, AOTA has developed the Occupational Profile Template, which can be used across practice settings and areas. Download the AOTA Occupational Profile Template (pdf). The template can be printed and completed by hand during the evaluation or can be incorporated into an electronic medical record.

The PDF version is a single page form that is better to use for printing to be completed by hand or for using digitally to attach to documentation. When using Adobe Acrobat Reader, the text size is responsive and the 1-page limit will be maintained. This version was tested with Adobe Acrobat Reader which can be downloaded for free from www.adobe.com/reader. Not all features (including responsive text) will work with other software.

Download PDF Template

The Word version is better to use when the length of the document is not important, and you prefer to have all text the same size. When using this version, the fields expand to create multiple pages, but the text size is uniform. This version was tested with Microsoft Word. Other software may or may not work as intended. 

Download Word Template

Read occupational profile examples based on actual clients in a variety of settings. Each client is unique and their profile will reflect that, but these samples show how your colleagues are using the AOTA Occupational Profile Template. Read examples from actual clients.

How To Use the Template in Electronic Health Records

AOTA welcomes clinical feedback on the template at quality@aota.org. Consult the Occupational Therapy Practice Framework: Domain and Process, 3rd Edition (AOTA, 2014) for detailed definitions and a description of the occupational therapy process, including the occupational profile.

Reference

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006