97166 Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or

Name of the Procedure:

Occupational Therapy Evaluation, Moderate Complexity

Summary

An Occupational Therapy evaluation of moderate complexity involves creating a detailed occupational profile for the patient and reviewing their medical and therapy history. This includes an expansive look at medical and/or therapy records and a supplementary review of physical, cognitive, or psychosocial aspects to better understand the patient's abilities and challenges.

Purpose

This evaluation aims to understand the patient's functional capabilities and issues related to their daily activities. The assessment helps to develop a personalized therapy plan that promotes independence and enhances quality of life.

Indications

• Difficulty performing daily activities (e.g., dressing, cooking, bathing)
• Changes in physical ability due to injury, illness, or surgery
• Cognitive impairments affecting daily functioning
• Developmental delays in children
• Psychosocial issues impacting daily living

Preparation

• Patients should bring any relevant medical and therapy records.
• No specific physical preparation is generally required.
• Patients may be asked to complete questionnaires or assessments prior to the appointment.

Procedure Description

1. Occupational Profile Creation: The therapist interviews the patient to gather information on their daily routines, roles, and goals.
2. Review of Medical and Therapy History: Expanded review of medical records, previous therapy notes, and assessments.
3. Assessments: Detailed evaluation of physical, cognitive, and psychosocial aspects through standardized tests and observations.
4. Discussion: The therapist discusses initial findings with the patient and may begin to outline a possible intervention plan.

Tools and Equipment:

• Standardized assessment tools and questionnaires
• Observation checklists

Anesthesia or Sedation:

• Not applicable

Duration

The procedure typically takes 1 to 1.5 hours.

Setting

The evaluation is usually performed in an outpatient clinic, hospital, or rehabilitation center.

Personnel

• An Occupational Therapist (OT)

Risks and Complications

• There are minimal risks associated with this evaluation.
• Misinterpretation of results leading to an inappropriate therapy plan (though rare and correctable).

Benefits

• A detailed understanding of the patient’s strengths and areas needing support.
• Development of a customized therapy plan to enhance daily functioning and quality of life.
• Benefits can often be realized shortly after intervention begins, depending on the complexity of the issues addressed.

Recovery

• No recovery time required as this is a non-invasive assessment.
• Follow-up sessions will be planned based on the initial evaluation findings and therapy goals.

Alternatives

• Self-assessment and patient-reported outcome measures (less comprehensive and may not provide an in-depth understanding).
• General physical therapy assessment focusing solely on physical impairments without the holistic approach of occupational therapy.

Patient Experience

• Patients may feel a mix of discussion and hands-on testing during the evaluation.
• Minimal discomfort as the process involves interviews and simple tasks or questionnaires.
• Comfort measures include a welcoming environment and clear communication throughout the session.