97165 Occupational therapy evaluation, low complexity, requiring these components: 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; An

Name of the Procedure:

Occupational Therapy Evaluation, Low Complexity

• Common Name(s): OT Eval, Initial OT Assessment
• Technical Term: Low Complexity Occupational Therapy Evaluation

Summary

An occupational therapy evaluation of low complexity involves gathering an occupational profile and reviewing medical and therapy history to address a specific problem. This assessment helps in understanding the patient's daily activities and abilities to develop a tailored treatment plan.

Purpose

• Medical Condition: This procedure addresses conditions affecting daily living activities, such as injuries, disabilities, developmental delays, or chronic illnesses.
• Goals: The primary goal is to identify the patient’s specific needs and challenges, leading to a customized therapeutic intervention plan aimed at improving independence and quality of life.

Indications

• Symptoms: Difficulty in daily living activities, such as dressing, eating, or mobility.
• Patient Criteria: Suitable for patients with a straightforward, single health issue or condition that impacts their daily functioning and participation.

Preparation

• Pre-Procedure Instructions: No specific preparation is generally required.
• Necessary Assessments: May include medical records forms to fill in or bringing in relevant medical and/or therapy records.

Procedure Description

1. Occupational Profile: The therapist conducts an interview to gather information about the patient’s daily routines, roles, and environment.
2. Medical and Therapy History: A brief history is taken, including a review of medical and/or therapy records related to the presenting problem.
3. Assessment: The therapist may conduct simple functional assessments to evaluate the patient’s abilities and challenges.
   • Tools: Basic assessment tools like questionnaires and observational checklists.
   • Anesthesia: Not applicable.

Duration

Typically takes about 30-60 minutes.

Setting

Performed in a variety of settings including hospitals, outpatient clinics, rehabilitation centers, or even at the patient’s home.

Personnel

Conducted by a licensed and registered occupational therapist.

Risks and Complications

• Common Risks: Minimal, as this is a non-invasive procedure.
• Rare Risks: Misinterpretation of history or assessment results leading to an inadequate treatment plan; easily managed with follow-up evaluations if necessary.

Benefits

• Expected Benefits: A comprehensive understanding of the patient’s needs and customized therapeutic strategies to enhance daily living and independence.
• Realization: Benefits can often be seen shortly after commencing the tailored therapy plan.

Recovery

• Post-Procedure Care: None required beyond typical daily activities.
• Recovery Time: Immediate, as no physical intervention occurs within this evaluation stage.
• Follow-Up: May include scheduling subsequent therapy sessions based on the evaluation findings.

Alternatives

• Other Options: Detailed or more sophisticated assessments for complex cases.
• Pros and Cons: Alternatives may provide more comprehensive data but can be more time-consuming and resource-intensive compared to a low complexity evaluation.

Patient Experience

• During: The patient can expect a straightforward discussion about their daily life and the challenges they face.
• After: Usually, no discomfort or pain; potentially a sense of relief from having a clear plan to address their issues.
• Pain Management: Not applicable.