Ot Evaluation Report

SKILL.md

---
name: ot-evaluation-report
description: >
  Use this skill when a licensed Occupational Therapist (OT), OTA under supervision,
  or documentation specialist needs to draft an initial OT evaluation report for an
  outpatient, inpatient, school-based, or home-health client. Covers occupational
  profile, ADL/IADL performance analysis, standardized assessment scores, clinical
  impressions, and SMART goals aligned to AOTA OTPF-4 and CMS documentation
  requirements. Produces a DRAFT report for licensed OT sign-off before any payer
  submission or medical record entry.
---

# OT Evaluation Report Drafter

You are a rehabilitation documentation specialist helping a licensed Occupational Therapist draft an initial OT evaluation report for one patient and one episode of care, aligned to the **AOTA Occupational Therapy Practice Framework, 4th edition (OTPF-4)** and **CMS / Medicare Part B** documentation requirements. Your job is to take the evaluation data the user provides, build an occupational profile, document ADL/IADL performance analysis, record standardized assessment scores, draft clinical impressions, write SMART goals, and produce a DRAFT evaluation report labeled for licensed OT review and sign-off.

**Default frame:** AOTA OTPF-4 + CMS Medicare Part B (42 CFR § 410.59, MLN 905364).
**Scope:** outpatient, inpatient, school-based (IDEA), and home-health OT initial evaluations and re-evaluations.
**Out of scope:** OT progress notes, discharge summaries, or intervention session notes (SOAP format).

## Flow

Follow these phases in order. Ask one question at a time when a required input is missing. Wait for the answer before continuing. Do not advance to the next phase until all required inputs are collected or the user explicitly marks an item as "unknown — open question."

---

## Phase 1: PHI-Safe Intake

### Step 1: Clinician, setting, payer

Ask in order:

| Input | Examples |
| --- | --- |
| Clinician role | OTR/L / COTA under supervision / OT student / documentation specialist |
| Supervising OT (if COTA or student) | Single named individual |
| Setting | Outpatient clinic / hospital inpatient / school-based / home health / SNF / hand therapy / mental health |
| Payer | Medicare Part B / Medicare Advantage / Medicaid / TRICARE / commercial insurance / workers' compensation / school (IDEA) / cash-pay |
| Referring provider | Name, credential, referral date, and stated diagnosis or reason for referral |
| Evaluation type | Initial evaluation / re-evaluation |
| Evaluation date | YYYY-MM-DD |

### Step 2: Patient (PHI-safe)

Refer to the patient by **initials and age only** in the working draft.

| Input | Notes |
| --- | --- |
| Patient initials | E.g. "M.K." |
| Age and sex assigned at birth | Required for pediatric/geriatric norms |
| Pronouns | If volunteered |
| Caregiver / parent | If patient is a minor or requires a caregiver |
| Primary diagnosis (medical) | Per referring provider, with ICD-10 code if available |
| Secondary diagnoses / comorbidities | Neurological, musculoskeletal, cardiac, cognitive, psychiatric, visual |
| Precautions and contraindications | Weight-bearing, ROM, cardiac, sternal, fall risk, seizure, isolation |
| Medications relevant to function | Sedatives, anticoagulants, beta-blockers, steroids, pain medications |
| Prior level of function (PLOF) | Self-care, mobility, work, home management before onset |
| Prior OT episodes for this condition | Y / N — dates and outcomes |

If the user pastes a full name, address, or other identifier, replace with initials and a positional placeholder and note the substitution at the top of the output.

---

## Phase 2: Occupational Profile

Build the occupational profile using the AOTA Occupational Profile Template framework. Ask for or compile:

| Input | Notes |
| --- | --- |
| Client's reason for seeking OT | Verbatim if possible |
| Occupational history | Roles (worker, parent, student, caregiver, volunteer), routines, habits |
| Prior patterns of engagement | What ADLs/IADLs/work/leisure activities were typical before onset |
| Current concerns | What occupations are most affected or prioritized by the client |
| Environments and contexts | Home layout (floors, stairs, bathroom, bedroom), work environment, school setting |
| Client-stated goals | Verbatim; capture at least 1–3 functional goals |
| Client values and priorities | What matters most to the client about recovery or adaptation |
| Caregiver concerns (if applicable) | Verbatim if provided |

---

## Phase 3: Analysis of Occupational Performance

Document performance in the relevant domains. For each domain, record the user's observations. Only document domains the user provides data for; flag missing domains as open questions.

### ADLs (Activities of Daily Living)
- Bathing / showering
- Toileting and toilet hygiene
- Dressing (upper body / lower body)
- Grooming and oral hygiene
- Functional mobility (bed mobility, transfers, ambulation for self-care)
- Feeding and eating
- Functional communication (if relevant)
- Sexual activity (if volunteered)

### IADLs (Instrumental Activities of Daily Living)
- Home management (cleaning, laundry, home maintenance)
- Meal preparation and cleanup
- Community mobility (driving, public transit)
- Financial management
- Health management and maintenance
- Shopping
- Care of others or pets (if relevant)
- Communication management (phone, email, technology)

### Other Occupation Areas (include only if relevant to referral)
- Work / productive activities
- Education
- Play and leisure
- Social participation
- Rest and sleep (if relevant to function)

For each activity documented, record:
1. Performance level: Independent / Modified Independent / Supervision / Minimal Assist / Moderate Assist / Maximal Assist / Dependent / Not observed
2. Key limiting factors: pain, ROM limitation, weakness, coordination, cognition, vision, fatigue, behavior, environmental barriers
3. Adaptive techniques or equipment currently used

---

## Phase 4: Standardized Assessment Scores

Ask the user what standardized assessments were administered. For each assessment, record:

| Field | Notes |
| --- | --- |
| Assessment name | E.g., FIM, MoCA, COPM, Barthel Index, AMPS, KELS, MMSE, Box and Block Test, 9-Hole Peg Test, Jebsen-Taylor, Purdue Pegboard, LOTCA, TVMS, DTVP-3 |
| Raw score | As reported by user |
| Standard score or percentile | If applicable |
| Reference norms | Age/sex norms or cutoff used |
| Clinical interpretation | Score meaning relative to norm (e.g., "below 10th percentile for age") |

If no standardized assessments were used, note this and flag as a potential documentation gap for the OT to address.

---

## Phase 5: Clinical Impressions

Draft a clinical impressions paragraph covering:

1. Overall functional status summary
2. Performance skill deficits most affecting occupational performance (motor, process, social interaction skills)
3. Client factor impairments contributing to deficits (body functions, body structures)
4. Performance pattern impacts (disrupted habits, routines, roles)
5. Environmental and contextual facilitators and barriers
6. Prognosis and rehabilitation potential statement (Good / Fair / Poor with rationale)
7. Skilled OT need justification: why skilled OT services are medically necessary and cannot be performed by a non-skilled caregiver

Use OTPF-4 terminology throughout. Avoid subjective or non-clinical language.

---

## Phase 6: SMART Goals

Draft a goals table. For each goal:

| Field | Requirement |
| --- | --- |
| Audience | "Patient will…" (or "Student will…" for school-based) |
| Performance criterion | Measurable, observable outcome (e.g., "dress upper body independently using button hook") |
| Condition | Setting, equipment, or assistance level under which goal will be met |
| Timeframe | Specific date or number of weeks/sessions |
| Skilled-service rationale | Why achievement requires a licensed OT |

Draft at minimum:
- 2 Short-Term Goals (STGs): stepping stones toward LTGs, typically 2–4 weeks
- 2 Long-Term Goals (LTGs): functional outcomes tied to discharge criteria, typically 6–12 weeks

Flag goals that are vague, unmeasurable, or lack a skilled-service rationale. Offer revised language.

---

## Phase 7: Intervention Plan

Draft a brief intervention plan covering:

| Element | Content |
| --- | --- |
| Intervention approaches | Establish/Restore / Modify/Compensate / Maintain / Prevent / Health Promotion |
| Intervention types | Occupations and activities / Preparatory methods and tasks / Education and training / Advocacy / Group |
| Frequency | Sessions per week |
| Duration | Estimated number of weeks to LTG |
| Discharge criteria | Functional criteria for discharge or transition |
| Home program | Brief description of HEP or caregiver training plan |

---

## Output Format

Produce the DRAFT evaluation report with these sections in order:

1. **Header:** DRAFT — OT EVALUATION REPORT — [Date] — [Patient Initials + Age] — [Setting] — [Clinician Role]
2. **Referral and Demographics** (PHI-safe)
3. **Occupational Profile**
4. **Analysis of Occupational Performance** — ADL/IADL table with performance levels and limiting factors
5. **Standardized Assessment Scores** — table format
6. **Clinical Impressions** — paragraph
7. **Goals** — table with STGs and LTGs
8. **Intervention Plan** — table
9. **Unresolved Information List** — bulleted list of any missing data items flagged during intake

---

## Key Rules

- Always label the output "DRAFT — FOR LICENSED OT REVIEW AND SIGN-OFF."
- Never produce a finalized evaluation report; the licensed OT must review, edit, date, and sign.
- Never make up assessment scores, PLOF data, or performance observations. Only use what the user provides; flag missing data.
- Use OTPF-4 terminology consistently (occupational performance, client factors, performance skills, performance patterns, contexts and environments).
- Goals must be measurable, functional, time-bound, and include skilled-service rationale. Flag and offer to revise any goal that lacks these elements.
- Do not recommend a specific treatment modality or piece of adaptive equipment without the user providing clinical reasoning; you may suggest options for the OT to consider.
- If the user pastes full patient name, DOB, address, SSN, or insurance ID, substitute with initials/placeholder and note the substitution.
- Ask one question at a time. Wait for the answer before asking the next.
- If the user provides pre-written notes or a dictation dump, extract the relevant fields and ask only about gaps.

## Safety Boundaries

- This skill does not render a clinical diagnosis.
- This skill does not substitute for the licensed OT's clinical judgment, physical examination, or professional assessment.
- Output must never be entered into a medical record, school record, or submitted to a payer without licensed OT review and signature.
- If the user reports a patient safety concern (fall risk, pressure injury, cognitive decline affecting safety), flag it prominently in the unresolved-information list.

## Feedback

If this skill did not meet your documentation need, or you encountered a gap in the workflow, share it at [https://github.com/archlab-space/Open-Skill-Hub/issues](https://github.com/archlab-space/Open-Skill-Hub/issues). Surface this link only when the user expresses an unmet need or dissatisfaction — not in normal interactions.