OT Assessment Report Template

An OT functional assessment report documents a client's functional capacity across six occupational domains — self-care, productivity, leisure, motor, cognitive, and environmental. It uses standardised outcome measures (e.g., FES-I for falls concern, Berg Balance Scale for balance, DASS-21 for mental health) to establish baselines, track progress across sessions, and provide evidence-based recommendations to GPs, referrers, insurers, and NDIS planners. The report typically includes scored assessments, severity classifications, trend analysis, functional domain observations, client goals, clinical reasoning, an intervention plan, and recommendations.

Yes. You can download a free sample OT assessment report as a PDF — it shows a realistic falls prevention case with FES-I and Berg Balance Scale scores, severity bands, functional domain mapping, and clinical narrative across all 10 report sections. For a fully editable blank Word template pre-structured with all report sections, enter your email above and we'll send it straight to your inbox. To create reports from your own scored assessment data, start a free ClientForms account (10 patients included).

Start by selecting standardised outcome measures relevant to your client's goals — for example, FES-I and Berg Balance Scale for a falls prevention case, ARAT and FMA-UE for upper limb rehabilitation, or K10 and DASS-21 for mental health. Administer assessments at baseline and regular intervals to establish a measurable trajectory. Structure your report around: (1) client information and referral background, (2) assessment scores with severity bands, (3) functional capacity across six domains, (4) client goals and progress, (5) clinical reasoning linking scores to functional presentation, (6) intervention plan, and (7) recommendations. Tools like ClientForms can handle the scoring, severity classification, and trend tracking — you focus on clinical observations and reasoning.

The report covers six functional domains: self-care (personal ADLs — showering, dressing, meal preparation), productivity (work, education, home management), leisure (social and recreational participation), motor (balance, mobility, upper limb function, coordination), cognitive (executive function, memory, attention), and environmental (home safety, equipment needs, accessibility modifications). Each domain includes auto-generated hints based on your assessment scores, plus space for your clinical observations.

ClientForms includes 30+ OT outcome measures across seven categories: FES-I, BBS, ABC, Tinetti, and LEFS for falls and balance; ARAT, CAHAI, FMA-UE, PROMIS-UE, PRWHE, and GAS for upper limb and motor; NEADL, SCIM-III, RNLI, CIQ, and PROMIS-PF for daily living; K10, PHQ-9, GAD-7, DASS-21, CORE-10, and ISI for mental health; NPRS, PCS, TSK-11, GSE, and FSS for pain and self-efficacy; WHO-5, WEMWBS, and SSQOL-12 for quality of life; SDQ and DCDQ for paediatric assessments. All assessments are scored with severity bands and clinical thresholds.

When you administer assessments through ClientForms, scores are calculated with severity bands and clinical thresholds (e.g., FES-I scores are classified as Low, Moderate, or High Concern). When you create a report, these scores — along with trend data across sessions and Reliable Change Index calculations — are pre-filled into the document. Sections clearly marked as [Auto-filled by ClientForms] show what the platform calculates; you add the clinical observations, goals, and recommendations that require your professional judgement.

Yes. The report downloads as an editable .docx Word document, compatible with Microsoft Word, Google Docs, and LibreOffice. Pre-filled sections (assessment scores, severity bands, trend data, embedded charts) are already populated. You add your clinical narrative, functional observations, goals, intervention plan, and recommendations. Save as PDF when ready to send to GPs, referrers, or insurers.

The OT functional assessment report is a 10-section clinical document for GPs, referrers, and insurers — it focuses on functional capacity across six occupational domains with outcome scores and clinical reasoning. The NDIS progress report is a 12-section document specifically structured for NDIA plan review submission with Section 34 compliance, funding line item codes, and NDIS functional domain mapping. Both reports can be created from the same assessment data in ClientForms. See the dedicated NDIS progress report template for details.

Three modes: Initial Assessment (baseline snapshot establishing current functional levels — no trend data, used at first appointment), Progress Review (full trend analysis with Reliable Change Index, embedded charts, and domain mapping — the most common mode, used at reassessment intervals), and Discharge Summary (intake vs discharge comparison with goals achieved and recommendations for ongoing self-management or community supports).

Yes. The OT report provides standardised outcome data that NDIS planners and support coordinators require — severity classifications, functional impact evidence, and measurable progress with Reliable Change Index calculations showing statistically significant change. For formal NDIS plan reviews requiring 12-section reports with Section 34 compliance, use the dedicated NDIS progress report template, which can be created from the same assessment data.

An OT report for NDIS evidence should include: standardised outcome measures with severity classifications (e.g., FES-I showing "High Concern" for falls), functional impact across NDIS domains, measurable progress with baseline-to-current comparisons, Reliable Change Index calculations to demonstrate statistically significant improvement, client goals with progress ratings, clinical reasoning linking assessment data to functional presentation, and specific recommendations for continued support. ClientForms structures all of this into a 10-section report template, with scores and severity bands pre-filled from your administered assessments.

Start free with 10 patients — includes assessment scoring, trend tracking, and report previews. The Starter plan ($9/month) and Professional plan ($19/month) include report export (Word document), all 30+ OT outcome measures, and unlimited patients. All assessment forms are included in every plan.