OT 792/892 Level I - Guided Observation
Clinical Setting: _____________________________________
Date: ________________________
Reason client is seeking/receiving OT services:____________________________________________________
Goal of OT Session: _________________________________________________________________________
Observation
Evidence
Client’s Demeanor at
Initiation of Session
What is the client’s appearance and behavior (in the waiting room or
entering the session)?
Client Factors
What are the client’s values and interests?
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•
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Values, beliefs, spirituality
Body functions (e.g., mental,
sensory, movement-related,
cardiovascular)
Body structures (e.g., structures
of the nervous system, eyes and
ears, related to movement)
Performance Patterns
(e.g., habits, routines, roles, rituals)
Psychosocial Factors
What client factors does the client see as supporting engagement in desired
occupations, and what aspects are inhibiting engagement (e.g., pain, active
symptoms)?
What are the client’s patterns of engagement in occupations, and how have
they changed over time? What are the client’s daily life roles? (Patterns
can support or hinder occupational performance.)
Describe any psychosocial factors that you notice with the client in the
clinical setting:
What did you notice the clinician do to support (or maybe hinder) this
client’s psychosocial adjustment or skills?
Contexts
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•
Environment (e.g., natural
environment and human-made
changes, products and
technology, support and
relationships, attitudes, services,
systems and policies)
Personal Factors (e.g., age,
sexual orientation, gender
identity, race/ethnicity, cultural
identification, social
background, upbringing,
psychological assets, education,
lifestyle)
What aspects of their contexts (environmental and personal factors) does
the client see as supporting engagement in desired occupations, and what
aspects are inhibiting engagement?
Supporting
Inhibiting
Performance Skills (motor
skills, process skills, social
interaction skills)
How effectively does the client move self or objects, organize and adapt,
and use verbal and nonverbal communication skills?
Areas of Occupation
What are the client’s current concerns relative to engaging in occupations
and in daily life activities?
In what occupations does the client feel successful, and what barriers are
affecting their success in desired occupations?
Assessments Administered /
Interventions Utilized
Are standardized assessments used? Are informal assessments used? If so,
which ones and what is being assessed?
Practitioner’s Therapeutic
Use of Self
How does the therapist use his/her/their personality, insights, perceptions,
and judgments as part of the therapeutic process?
•
Creates a meaningful
relationship between the
therapist and the patient in order
to produce meaningful
participation and progress in
occupations that matter to the
patient.
Client’s Response to
Evaluation/Intervention
Session
How does intervention relate to the assessment and to the goals of this
client?
Ideas for Future Sessions
Other Observations
Adapted from https://www.aota.org/~/media/Corporate/Files/Practice/Manage/Documentation/AOTA-Occupational-ProfileTemplate.pdf
Resource: American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th
ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001