How to Complete an OT Initial and Home Assessment

An initial and home assessment can involve a lot of information.

You may be meeting a client for the first time, gathering their history, understanding their goals, assessing their functional capacity and then looking at how their home environment is impacting their independence and safety.

It can be a lot to cover.

A good initial and home assessment should give you a clear picture of the person, their function, their environment and what they may need to improve their safety, independence and participation.

While every assessment will be different, an OT initial assessment will commonly consider:

• Reason for referral

• Relevant medical and personal history

• Current formal and informal supports

• Client goals

• Mobility and transfers

• Falls history

• Vision and hearing

• Cognition and communication

• Upper limb and sensory function

• Current assistive technology

• Personal care

• Domestic activities

• Community access

• Leisure and social participation

The assessment should be tailored to the individual rather than simply working through a checklist.

What should you assess in the home?

A home assessment should consider how the environment supports - or creates barriers to - the client's everyday function.

Depending on the client, this may include:

• Entry and exit

• Steps, ramps and rails

• Bathroom and toilet

• Laundry

• Kitchen

• Living areas

• Bedroom

• Existing equipment

• Transfers and access within the home

• Safety concerns

It's important to consider not just how the home is designed, but how the client is actually using the space.

Where does clinical reasoning come in?

The assessment shouldn't simply identify problems. You also need to consider what those problems mean functionally and what could improve the situation.

For example:

Difficulty accessing shower → increased risk and reliance on assistance → consideration of equipment or home modification → improved safety and independence.

Your recommendations should be clearly connected to your assessment findings, the client's goals and their functional needs.

An assessment shouldn't only focus on limitations. Consider:

• What can they do independently?

• What are they able to do with support?

• What are they motivated to do?

• What activities are important to them?

• What could improve their independence?

This helps create a more balanced picture of the client's functional capacity.

Before you finalise your assessment, ask yourself:

Have I clearly explained:

☐ Why the client was referred

☐ What their current functional capacity is

☐ What they can do independently

☐ What they require assistance with

☐ What barriers exist within their environment

☐ What risks have been identified

☐ What could improve their safety or independence

☐ Why your recommendations are appropriate

☐ How the recommendations relate to their goals

If the reader can follow the pathway from client → function → environment → barriers → recommendations, your assessment is much easier to understand.

Need a starting point for your next assessment?

My Combined Initial & Home Assessment Template provides a structured framework to help you work through the client's history, functional capacity, ADLs and iADLs, home environment and recommendations, while still allowing you to tailor the assessment to each individual client.

Templates should always be adapted to the individual client, your clinical findings and your professional requirements.