In simple words: A low-complexity occupational therapy evaluation assesses a patient's ability to perform daily activities related to work, home, and other areas of life. The therapist reviews the patient's medical history, assesses 1-3 areas of difficulty, and considers a few treatment options. This evaluation usually takes about 30 minutes.

Occupational therapy evaluation, low complexity, requiring these components:1. An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem.2. An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.3. Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options.4. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.

Example 1: A patient post-stroke is referred for an initial evaluation to assess their ability to perform daily tasks and develop a rehabilitation plan., An employee with carpal tunnel syndrome is evaluated to determine work-related limitations and explore treatment options., A child with developmental delays undergoes an evaluation to identify areas needing intervention and create a treatment plan.

Documentation must include the occupational profile, medical and therapy history, assessment results identifying 1-3 performance deficits, clinical decision-making process, and the plan of care.