The Association

Improve Your Documentation and Quality of

Care With AOTA’s Updated Occupational
Profile Template

T he Occupational Therapy Practice Framework: Domain and Process—Fourth Edition (OTPF-4; American
Occupational Therapy Association [AOTA], 2020) states that every occupational therapy evaluation includes (1) the
occupational profile and (2) the analysis of occupational performance. The OTPF-4 states that as the first step in the
evaluation process,
developing the occupational profile provides . . . an understanding of the client’s perspective and background. . . . During the process of collecting
this information, the client, with the assistance of the practitioner, identifies priorities and desired targeted outcomes that will lead to the client’s
engagement in occupations that support participation in daily life. Only clients can identify the occupations that give meaning to their lives and
select the goals and priorities that are important to them. By valuing and respecting clients’ input, practitioners . . . can more effectively guide
interventions. (AOTA, 2020, p. 21)
Consistently conducting and documenting the occupational profile is the first step in improving the quality of occupational
therapy services and demonstrating the profession’s distinct value to other health care providers, reviewers, and payers.
The profile demonstrates occupational therapy practitioners’ commitment to clients as collaborators in the occupational
therapy process and facilitates client-centered practice. In addition, the occupational therapy evaluation and reevaluation
Current Procedural Terminology® codes established in 2017 require the inclusion of an occupational profile.
To assist occupational therapy practitioners in conducting an occupational profile with each client, AOTA has
developed the Occupational Profile Template, which can be used across practice settings and areas. The template can
be printed and completed by hand during the evaluation, or it can be incorporated into an electronic medical record.
The PDF version is a single-page form that is better to use for printing (if the document is being completed by hand) or
for using digitally to attach to documentation. When using Adobe Acrobat Reader, the text size is responsive, and the
one-page limit will be maintained. This version was tested with Adobe Acrobat Reader, which can be downloaded for
free from https://www.adobe.com/reader. Not all features, including responsive text, will work with other software.
The Word version is better to use when the length of the document is not important, and you prefer to have all text the
same size. When using this version, the fields expand to create multiple pages, but the text size is uniform. This version
was tested with Microsoft Word; other software may not work as intended.
Occupational profile examples based on actual clients in a variety of settings are available on the AOTA website.
Each client is unique and their profile will reflect that, but these samples show how your colleagues are using the AOTA
Occupational Profile Template. Information on using the Occupational Profile Template in electronic health records is
also available from AOTA. AOTA welcomes clinical feedback on the template at quality@aota.org.
Refer to the OTPF-4 for detailed definitions and a description of the occupational therapy process, including the
occupational profile.

Reference
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of
Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Citation: American Occupational Therapy Association. (2021). The Association—Improve your documentation and quality of care with AOTA's updated
Occupational Profile Template. American Journal of Occupational Therapy, 75, 7502420010. https://doi.org/10.5014/ajot.2021.752001

The American Journal of Occupational Therapy, March/April 2021, Vol. 75, No. 2 7502420010p1
 aota.org

AOTA Occupational Profile Template

“The occupational profile is a summary of a client’s (person’s, group’s, or population’s) occupational history and experi-
ences, patterns of daily living, interests, values, needs, and relevant contexts” (AOTA, 2020, p. 21). The information is
obtained from the client’s perspective through both formal and informal interview techniques and conversation.

The information obtained through the occupational profile contributes to a client-focused approach in the evaluation,
intervention planning, intervention implementation, and discharge planning stages. Each item below should be addressed
to complete the occupational profile. Page numbers are provided to reference the description in the Occupational
Therapy Practice Framework: Domain and Process (4th ed.; AOTA, 2020).

OCCUPATIONAL PROFILE
Reason the client is seeking Why is the client seeking services, and what are the client’s current
service and concerns related to concerns relative to engaging in occupations and in daily life
engagement in occupations activities? (This may include the client’s general health status.)
(p. 16)
In what occupations does the client feel successful, and what
Occupations in which the client
Client Report

barriers are affecting their success in desired occupations?

is successful and barriers
affecting success (p. 16)

What is the client’s occupational history (i.e., life experiences)?

Occupational history (p. 16)

What are the client’s values and interests?

Personal interests and values
(p. 16)

What aspects of their contexts (environmental and personal factors)

does the client see as supporting engagement in desired
occupations, and what aspects are inhibiting engagement?
Supporting Engagement Inhibiting Engagement
Environment (p. 36)
(e.g., natural environment and
human-made changes, products
Contexts

and technology, support and

relationships, attitudes, serv-
ices, systems and policies)

Personal (p. 40) Supporting Engagement Inhibiting Engagement

(e.g., age, sexual orientation,
gender identity, race and ethni-
city, cultural identification,
social background, upbringing,
psychological assets, educa-
tion, lifestyle)
©2020 by the American Occupational Therapy Association.
 What are the client’s patterns of engagement in occupations, and how
Performance have they changed over time? What are the client’s daily life roles?
Patterns Performance patterns (p. 41) (Patterns can support or hinder occupational performance.)
(e.g., habits, routines, roles,
rituals)

What client factors does the client see as supporting engagement in

desired occupations, and what aspects are inhibiting engagement (e.g.,
pain, active symptoms)?
Supporting Engagement Inhibiting Engagement
Values, beliefs, spirituality
(p. 51)
Client Factors

Body functions (p. 51) Supporting Engagement Inhibiting Engagement

(e.g., mental, sensory, neuro-
musculosketal and movement-
related, cardiovascular
functions)
Supporting Engagement Inhibiting Engagement
Body structures (p. 54)
(e.g., structures of the nervous
system, eyes and ears, related
to movement)

What are the client’s priorities and desired targeted outcomes

related to the items below?
Occupational Performance

Prevention

Health and Wellness

Client Goals

Client’s priorities and desired Quality of Life

targeted outcomes (p. 65)
Participation

Role Competence

Well-Being

Occupational Justice

For a complete description of each component and examples of each, refer to the Occupational Therapy
Practice Framework: Domain and Process (4th ed.).
Resources
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and
process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://
doi.org/10.5014/ajot2020.74S2001
The occupational therapy evaluation and reevaluation CPT® codes established in 2017 require the inclusion
of an occupational profile. For more information, visit https://www.aota.org/coding.

©2020 by the American Occupational Therapy Association.