The occupational therapist (OT) performs an evaluation requiring clinical decision–making of moderate analytic complexity, which includes analysis of occupational profile, problem–focused assessment data, and consideration of several treatment options, on a patient who presents with health issues that affect occupational performance. The evaluation includes an occupational profile, expanded medical and therapy history including therapy relating to a current problem, and evaluation of three to five physical, cognitive, or psychosocial performance factors that limit activity or restrict participation. Evaluation components can be completed with minimal to moderate modification of tasks or assistance, such as physical or verbal, resulting in several treatment options, and typically in 45 minutes of face–to–face time with the patient or family or both.
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