Evaluation and Assessment · 4 min read
Client History and Occupational Profile
Purpose of the Occupational Profile
The occupational profile is the foundation of occupational therapy evaluation. It captures who the client is, what matters to them, and what they need or want to do. The profile guides all subsequent evaluation and intervention decisions.
An occupational profile includes the client's occupational history, patterns of daily living, interests, values, and needs. It identifies what occupations are successful, problematic, or at risk. The therapist gathers information about contexts, both environmental factors and personal factors, that support or hinder occupational performance.
Components of Client History
Client history encompasses medical, developmental, social, educational, and occupational information. Medical history includes diagnoses, surgeries, hospitalizations, medications, and precautions. Developmental history is particularly relevant for pediatric clients and includes milestones, prenatal and birth history, and early intervention services.
Social history covers family structure, living situation, support systems, cultural background, and socioeconomic status. Educational history includes schooling completed, learning difficulties, and vocational training. Occupational history encompasses work experiences, volunteer activities, leisure pursuits, and role responsibilities.
Gathering Information
Information is gathered through interviews, questionnaires, record review, and observation. The client interview is the primary method for developing the occupational profile. The therapist uses open-ended questions to understand the client's perspective.
Key interview questions address what the client needs and wants to do, what barriers exist, what has changed, and what the client's priorities are. The therapist explores the client's roles, routines, and rituals. Cultural considerations influence how questions are asked and how information is interpreted.
When clients cannot provide information themselves, caregivers, family members, or other informants contribute. Medical records provide diagnostic information, precautions, and prior functional status. School records, employment records, and prior therapy documentation add relevant history.
Occupational History and Patterns
The therapist identifies the client's typical day structure, including wake and sleep times, meal patterns, work or school schedules, and leisure activities. Patterns of engagement reveal habits, routines, and rituals that support or hinder occupational performance.
Role identification includes productive roles such as worker, student, or homemaker; family roles such as parent, spouse, or caregiver; and community roles such as volunteer or organization member. Loss of roles due to injury, illness, or life transition is documented.
| Pattern | Definition | Example |
|---|---|---|
| Habits | Automatic behaviors performed with little thought | Putting keys in the same bowl every evening |
| Routines | Established sequences of occupations that structure daily life | Morning sequence of toileting, showering, dressing, breakfast |
| Roles | Sets of expected behaviors shaped by the client and society | Parent, worker, student, caregiver, volunteer |
| Rituals | Symbolic actions with spiritual, cultural, or social meaning | Holiday meals, religious observances, bedtime story |
Prior level of function establishes a baseline for goal setting. The therapist determines what the client could do before the current condition and what level of independence or assistance was typical.
Client Priorities and Goals
Client-centered practice requires understanding what matters most to the client. The therapist identifies the client's priorities for therapy and ensures that evaluation and intervention address those priorities.
The Canadian Occupational Performance Measure (COPM) is a standardized tool for identifying client priorities. The client identifies occupational performance problems and rates their importance, performance, and satisfaction. This information guides goal development and measures outcomes.
Contexts and Environments
In the current Occupational Therapy Practice Framework (OTPF-4), context is made up of environmental factors and personal factors. Earlier editions described cultural, personal, temporal, virtual, physical, and social contexts and environments; those ideas are now organized under these two categories.
| Component | What it includes | Examples |
|---|---|---|
| Environmental factors | Natural environment and human-made changes; products and technology; support and relationships; attitudes; services, systems, and policies | Stairs at the entrance, adaptive equipment, a supportive spouse, community attitudes toward disability, insurance coverage |
| Personal factors | Features of the person that are not part of a health condition | Age, gender identity, sexual orientation, race and ethnicity, cultural identification, social background, upbringing, education, profession, lifestyle |
Time-related considerations, such as time of day, duration, rhythm, and life stage, and virtual participation through electronic communication and technology still shape occupational engagement and are captured within these factors.
Environmental factors include the physical surroundings (natural and built spaces, objects, and accessibility features) and the social supports (relationships, expectations, and help available from others). Personal factors shape how the client experiences and responds to those surroundings.
Documentation of the Occupational Profile
The occupational profile is documented as a narrative summary or structured format. Key elements include client demographics, reason for referral, occupational history, current concerns, client priorities, contexts (environmental and personal factors), and factors supporting or hindering performance.
The profile establishes the foundation for selecting assessments, developing goals, and planning intervention. It is updated throughout the therapy process as new information emerges or client priorities change.
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