Evaluation and Assessment · 3 min read
Screening and Initial Assessment
Purpose of Screening
Screening determines whether further occupational therapy evaluation is warranted. It identifies potential problems in occupational performance without providing comprehensive assessment. Screening is efficient, brief, and broadly focused.
Screening may be conducted for populations at risk, such as developmental screening for infants, fall risk screening for older adults, or workplace injury screening for employees. Screening tools have established cutoff scores that indicate need for further evaluation.
Screening Methods
Observation provides quick information about functional status. The therapist observes posture, movement, communication, and interaction during initial contact. Brief performance tasks reveal general abilities and limitations.
Interview questions during screening focus on identifying problems. Questions address whether the client has difficulty with specific activities and whether function has changed recently.
Standardized screening tools provide reliable and valid identification of problems. Examples include the Denver II, a developmental screen for young children; the Mini-Mental State Examination (MMSE), a cognitive screen; and the Timed Up and Go (TUG) for fall risk. The Falls Efficacy Scale measures fear of falling (confidence in avoiding a fall), not fall risk itself.
Record review identifies diagnoses and conditions associated with occupational performance problems. Red flags in medical history prompt further evaluation in specific areas.
Components of Initial Assessment
Initial assessment is more comprehensive than screening and occurs after referral to occupational therapy. It includes the occupational profile plus evaluation of specific performance areas, skills, patterns, and client factors.
The initial assessment determines what additional evaluation is needed. It identifies areas of strength and limitation. It provides enough information to develop preliminary goals and initiate intervention while comprehensive evaluation continues.
| Feature | Screening | Evaluation |
|---|---|---|
| Purpose | Decide whether OT evaluation is needed | Identify strengths, problems, and priorities to plan intervention |
| Depth | Brief, broad | Comprehensive, focused on client priorities |
| Typical methods | Observation, brief interview, screening tools with cutoff scores, record review | Occupational profile plus standardized and nonstandardized assessments |
| Who is responsible | OT (an OTA may contribute when allowed by state law) | OT directs and interprets; an OTA may administer delegated assessments |
| Outcome | Refer for evaluation, refer elsewhere, or no further action | Problem list, goals, and intervention plan |
Prioritizing Evaluation Areas
Not every client requires evaluation in every domain. The occupational profile guides prioritization. The therapist evaluates areas relevant to the client's concerns, diagnosis, and functional needs.
Safety concerns receive priority. If the client has fall risk, cognitive impairment affecting safety, or self-harm potential, those areas are evaluated first. Medical precautions and contraindications influence evaluation choices.
Referral information suggests evaluation focus. A client referred for hand therapy receives upper extremity evaluation. A client referred for dementia care receives cognitive and functional evaluation. However, the therapist uses clinical judgment to expand evaluation beyond the referral focus when indicated.
Determining Need for Occupational Therapy Services
Initial assessment determines whether occupational therapy is appropriate. Criteria for occupational therapy services include identified problems in occupational performance, potential for improvement or maintenance of function, and goals that align with occupational therapy scope of practice.
If screening or initial assessment indicates no need for occupational therapy, the therapist documents findings and communicates with the referral source. If another service is more appropriate, the therapist makes referrals.
Communicating Initial Findings
Initial assessment findings are communicated to the client, family, and healthcare team. The therapist explains what was evaluated, what was found, and what the next steps are. Preliminary recommendations address immediate safety concerns and begin to establish the therapy relationship.
Documentation of initial assessment includes reason for referral, evaluation methods used, findings, preliminary problem list, and plan for further evaluation or intervention.
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