Occupational therapy assessment: report template and outline to download
The occupational therapy assessment process (prescription, autonomy evaluation, diagnosis, recommendations), the structure of the report, and its key role in the MDPH application. Template to download.
Countries covered : France
The occupational therapy assessment provides an objective measure of the patient's independence and results in a report that serves as a genuine medico-legal document: often decisive for an MDPH application. Performed under medical prescription, it is one of the most important documents of the profession.
This page details the framework, the process, the evaluation tools, the structure of the report, and its role in the MDPH application.
The framework to know
The process
- The interview (clinical history). Reason for referral, life context, daily activities (home, school/work), individual's goals.
- The evaluation. Standardized, calibrated tests and ecological assessments (observing a real-life activity).
- The occupational therapy diagnosis. Identifying the causes of breakdowns in autonomy.
- The report and recommendations. Linking identified impairments to solutions (rehabilitation, assistive devices, environmental modifications).
Evaluation tools
The occupational therapist combines ecological assessments and calibrated standardised tests. Depending on the area:
- Fine motor skills and dexterity: Purdue Pegboard, Box and Blocks.
- Visuospatial perception: DTVP.
- Graphomotor skills / writing: BHK.
- Attention and executive functions: NEPSY-II, TEA-Ch, Stroop.
- Independence in activities of daily living: dedicated questionnaires and scales.
Structure of an occupational therapy report
- Identification and prescription. Patient, prescriber, date, reason for referral.
- Clinical history and context. History, environment, daily activities, life goals.
- Complaint and objectives. What is expected from the intervention.
- Evaluation. Results of calibrated tests and real-life assessments, area by area.
- Occupational therapy diagnosis. The causes of breakdowns in autonomy.
- Quantified and justified recommendations. Rehabilitation, assistive devices, environmental modifications—each recommendation stems from an identified difficulty.
- Conclusion and transmission. Referral, transmission to the physician and, if applicable, to the MDPH.
Occupational therapy assessment template to download
Compatible with MDPH applications, follows the structure above, ready to fill out. Access the PDF by entering your email:
Save time on writing
The occupational therapy report is long: observations, results by area, justified recommendations. Start with a fixed template, standardise your diagnosis and recommendation phrasing, and dictate your observations right after the evaluation.
This is exactly what Delta does: you capture your observations live or via post-session dictation, and the tool generates a structured report based on your template, with a longitudinal patient memory that reuses the patient history from one assessment to the next. HDS hosting, GDPR compliant.
Frequently asked questions
Does an occupational therapy assessment require a medical prescription?
Yes. Occupational therapy only takes place under medical prescription, even in private practice (art. R4331-1 of the Public Health Code).
Is the occupational therapy assessment reimbursed?
No, not by Assurance Maladie in private practice (non-contracted profession, without official fee schedule). Funding is possible through the MDPH (PCH, AEEH) or certain supplementary health insurance companies (mutuelles).
How long does an assessment remain valid for the MDPH?
In general, it must be dated less than a year ago to be accepted.
What does the report contain?
Identification and prescription, clinical history and context, evaluation, occupational therapy diagnosis, and quantified and justified recommendations.
Which tools are used?
Ecological assessments and standardised tests depending on the area (e.g., Purdue Pegboard, Box and Blocks, DTVP, BHK, NEPSY-II, TEA-Ch).
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Delta generates your occupational therapy assessments from your live observations or dictation.
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