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The American Journal of Occupational Therapy 609
Occupational therapy is an evolving profession. Over the years,
the study ofhuman occupation and its components has enlightened the
profession aboutthe core concepts and constructs that guide
occupational therapy practice. In addi-tion, occupational therapys
role and contributions to society have continued toevolve. The
Occupational Therapy Practice Framework: Domain and Process
(alsoreferred to in this document as the Framework) is the next
evolution in a series ofdocuments that have been developed over the
past several decades to outline lan-guage and constructs that
describe the professions focus.
The Framework was developed in response to current practice
needstheneed to more clearly affirm and articulate occupational
therapys unique focus onoccupation and daily life activities and
the application of an intervention processthat facilitates
engagement in occupation to support participation in life.
Theimpetus for the development of the Framework was the review
process to updateand revise the Uniform Terminology for
Occupational TherapyThird Edition (UT-III) (American Occupational
Therapy Association [AOTA], 1994). The back-ground for the
development of the Framework is provided in a section at the endof
this document. As practice continues to evolve, the field should
consider thecontinued need for the Occupational Therapy Practice
Framework: Domain andProcess and should evaluate and modify its
format as appropriate.
The intended purpose of the Framework is twofold: (a) to
describe the domainthat centers and grounds the professions focus
and actions and (b) to outline theprocess of occupational therapy
evaluation and intervention that is dynamic andlinked to the
professions focus on and use of occupation. The domain and
processare necessarily interdependent, with the domain defining the
area of human activ-ity to which the process is applied.
This document is directed to both internal and external
audiences. The inter-nal professional audienceoccupational
therapists and occupational therapy assis-tantscan use the
Framework to examine their current practice and to considernew
applications in emerging practice areas. Occupational therapy
educators mayfind the Framework helpful in teaching students about
a process delivery modelthat is client centered and facilitates
engagement in occupation to support partici-pation in life. As
occupational therapists and occupational therapy assistants
moveinto new and expanded service arenas, the descriptions and
terminology providedin the Framework can assist them in
communicating the professions unique focuson occupation and daily
life activities to external audiences. External audiences canuse
the Framework to understand occupational therapys emphasis on
supportingfunction and performance in daily life activities and the
many factors that influ-ence performance (e.g., performance skills,
performance patterns, context, activitydemands, client factors)
that are addressed during the intervention process. The
Occupational Therapy Practice Framework: Domain and Process
ContentsDomain . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . .610
The Domain of Occupational Therapy . . . . . . . .
.610Engagement in Occupation to Support Participation in Context .
. . . . . . . . . . . . . . . . . . .611
Process . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . .613The Process of Occupational Therapy: Evaluation,
Intervention, and Outcome . . . . . . . . .613Framework Process
Organization . . . . . . . . . . . . .613Evaluation Process . . . .
. . . . . . . . . . . . . . . . . . . .615Intervention Process . .
. . . . . . . . . . . . . . . . . . . . .617Outcomes Process . . .
. . . . . . . . . . . . . . . . . . . . .618
An Overview of the Occupational Therapy Practice Process . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .619
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . .
. . . .619Appendix . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . .620
Table 1. Areas of Occupation . . . . . . . . . . . . . . .
.620Table 2. Performance Skills . . . . . . . . . . . . . . . .
.621Table 3. Performance Patterns . . . . . . . . . . . . . .
.623Table 4. Context or Contexts . . . . . . . . . . . . . . .
.623Table 5. Activity Demands . . . . . . . . . . . . . . . . .
.624Table 6. Client Factors . . . . . . . . . . . . . . . . . . . .
.624Table 7. Occupational Therapy InterventionApproaches . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . .627Table 8. Types
of Occupational Therapy Interventions . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .628Table 9. Types of Outcomes . . . . .
. . . . . . . . . . . .628Table 10. Occupational Therapy Practice
Framework Process Summary . . . . . . . . . . . . . . .629
Glossary (Framework) . . . . . . . . . . . . . . . . . . . . . .
. . .630References (Framework) . . . . . . . . . . . . . . . . . .
. . . . . .634Bibliography (Framework) . . . . . . . . . . . . . .
. . . . . . . .635Background . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .636
Background of Uniform Terminology . . . . . . . . .
.636Development of the Occupational Therapy Practice Framework:
Domain and Process . . . . . .636Relationship of the Framework to
the Rescinded UT-III and the ICF . . . . . . . . . . . . . . .
.637Comparison of Terms . . . . . . . . . . . . . . . . . . . . .
.637
References (Background) . . . . . . . . . . . . . . . . . . . .
. . .639Authors. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . .639
When citing this document the preferred reference is:
American Occupational Therapy Association. (2002).Occupational
therapy practice framework: Domain and process. American Journal of
Occupational Therapy,56, 609639.
-
description of the process will assist external audiences
inunderstanding how occupational therapists and occupa-tional
therapy assistants apply their knowledge and skills inhelping
people attain and resume daily life activities thatsupport function
and health.
The Occupational Therapy Practice Framework: Domainand Process
begins with an explanation of the professionsdomain. Each aspect of
the domain is fully described. Anintroduction to the occupational
therapy process followswith key statements that highlight important
points. Eachsection of the process is then specifically
described.Numerous resource materials, including an appendix,
aglossary, references, a bibliography, and the background ofthe
development of the Framework are supplied at the endof the
document.
DomainThe Domain of Occupational Therapy
A professions domain of concern consists of those areas ofhuman
experience in which practitioners of the professionoffer assistance
to others (Mosey, 1981, p. 51). Occupa-tional therapists and
occupational therapy assistants focuson assisting people to engage
in daily life activities that theyfind meaningful and purposeful.
Occupational therapysdomain stems from the professions interest in
humanbeings ability to engage in everyday life activities. Thebroad
term that occupational therapists and assistants use tocapture the
breadth and meaning of everyday life activityis occupation.
Occupation, as used in this document, isdefined in the following
way:
[A]ctivitiesof everyday life, named, organized, and givenvalue
and meaning by individuals and a culture.Occupation is everything
people do to occupy themselves,including looking after
themselvesenjoying lifeandcontributing to the social and economic
fabric of theircommunities. (Law, Polatajko, Baptiste, &
Townsend,1997, p. 32)
Occupational therapists and occupational therapy assis-tants
expertise lies in their knowledge of occupation andhow engaging in
occupations can be used to affect humanperformance and the effects
of disease and disability. Whenworking with clients, occupational
therapists and occupa-tional therapy assistants direct their effort
toward helpingclients perform. Performance changes are directed to
sup-port engagement in meaningful occupations that subse-quently
affect health, well-being, and life satisfaction.
The profession views occupation as both means andend. The
process of providing occupational therapy inter-vention may involve
the therapeutic use of occupation as ameans or method of changing
performance. The end of
the occupational therapy intervention process occurs withthe
clients improved engagement in meaningful occupa-tion.
Both terms, occupation and activity, are used by occu-pational
therapists and occupational therapy assistants todescribe
participation in daily life pursuits. Occupations aregenerally
viewed as activities having unique meaning andpurpose in a persons
life. Occupations are central to a per-sons identity and
competence, and they influence how onespends time and makes
decisions. The term activitydescribes a general class of human
actions that is goal direct-ed (Pierce, 2001). A person may
participate in activities toachieve a goal, but these activities do
not assume a place ofcentral importance or meaning for the person.
For example,many people participate in the activity of gardening,
butnot all of those individuals would describe gardening as
anoccupation that has central importance and meaning forthem. Those
who see gardening as an activity may reportthat gardening is a
chore or task that must be done as partof home and yard maintenance
but not one that they par-ticularly enjoy doing or from which they
derive significantpersonal satisfaction or fulfillment. Those who
experiencegardening as an occupation would see themselves as
gar-deners, gaining part of their identity from their
participa-tion. They would achieve a sense of competence by
theiraccomplishments in gardening and would report a sense
ofsatisfaction and fulfillment as a result of engaging in
thisoccupation. Occupational therapists and occupational ther-apy
assistants value both occupation and activity and recog-nize their
importance and influence on health and well-being. They believe
that the two terms are closely related yetrecognize that each term
has a distinct meaning and thatindividuals experience each
differently. In this documentthe two terms are often used together
to acknowledge theirrelatedness yet recognize their different
meanings.
The domain of occupational therapy frames the arenain which
occupational therapy evaluations and interven-tions occur. To make
the domain more understandable toreaders and easier to visualize,
the content of the domainhas been illustrated in Figure 1. At the
top of the page is theoverarching statementEngagement in Occupation
toSupport Participation in Context or Contexts. This state-ment
describes the domain in its broadest sense. The otherterms outlined
in the figure identify the various aspects ofthe domain that
occupational therapists and occupationaltherapy assistants attend
to during the process of providingservices. The three terms at the
bottom of the figure (con-text, activity demands, and client
factors) identify areas thatinfluence performance skills and
patterns. The two terms inthe middle of the figure (performance
skills and performancepatterns) are used to describe the observed
performance that
610 November/December 2002, Volume 56, Number 6
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the individual carries out when engaging in a range of
occu-pations. No one aspect outlined in the domain figure
isconsidered more important than another. Occupationaltherapists
are trained to assess all aspects and to apply thatknowledge to an
intervention process that leads to engage-ment in occupations to
support participation in context orcontexts. Occupational therapy
assistants participate in thisprocess under the supervision of an
occupational therapist.The discussion that follows provides a brief
explanation ofeach term in the figure. Tables included in the
appendixprovide full lists and definitions of terms.
Engagement in Occupation to Support Participation in Context
Engagement in occupation to support participation in con-text is
the focus and targeted end objective of occupationaltherapy
intervention. Engagement in occupation is seen asnaturally
supporting and leading to participation in con-text.
When individuals engage in occupations, they are com-mitted to
performance as a result of self-choice, motivation,and meaning. The
term expresses the professions belief in
the importance of valuing and considering the
individualsdesires, choices, and needs during the evaluation and
inter-vention process. Engagement in occupation includes boththe
subjective (emotional or psychological) aspects of per-formance and
the objective (physically observable) aspectsof performance.
Occupational therapists and occupationaltherapy assistants
understand engagement from this dualand holistic perspective and
address all the aspects of per-formance (physical, cognitive,
psychosocial, and contextu-al) when providing interventions
designed to supportengagement in occupations and in daily life
activities.
Occupational therapists and occupational therapy assis-tants
recognize that health is supported and maintainedwhen individuals
are able to engage in occupations and inactivities that allow
desired or needed participation inhome, school, workplace, and
community life situations.Occupational therapists and occupational
therapy assistantsassist individuals to link their ability to
perform daily lifeactivities with meaningful patterns of engagement
in occu-pations that allow participation in desired roles and life
sit-uations in home, school, workplace, and community. TheWorld
Health Organization (WHO), in its effort to broad-
The American Journal of Occupational Therapy 611
ENGAGEMENT IN OCCUPATION TO SUPPORT PARTICIPATION IN CONTEXT OR
CONTEXTS
n Performance in Areas of OccupationActivities of Daily Living
(ADL)*
Instrumental Activities of Daily Living (IADL)Education
WorkPlay
LeisureSocial Participation
(For definitions, refer to Appendix, Table 1)
n Performance SkillsMotor Skills
Process SkillsCommunication/Interaction Skills
(For definitions, refer to Appendix, Table 2)
n Performance PatternsHabits
RoutinesRoles
(For definitions, refer to Appendix, Table 3)
n ContextCulturalPhysicalSocial
PersonalSpiritualTemporal
Virtual(For definitions, refer to Appendix, Table 4)
n Activity DemandsObjects Used and Their Properties
Space DemandsSocial Demands
Sequencing and TimingRequired Actions
Required Body FunctionsRequired Body Structures
(For definitions, refer to Appendix, Table 5)
n Client FactorsBody FunctionsBody Structures
(For definitions, refer to Appendix, Table 6)
Figure 1. Domain of Occupational Therapy. This figure represents
the domain of occupational therapy and is included to allow readers
to visualizethe entire domain with all of its various aspects. No
aspect is intended to be perceived as more important than
another.
*Also referred to as basic activities of daily living (BADL) or
personal activities of daily living (PADL).
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en the understanding of the effects of disease and disabilityon
health, has recognized that health can be affected by theinability
to carry out activities and participate in life situa-tions as well
as by problems that exist with body structuresand functions (WHO,
2001). Occupational therapys focuson engagement in occupations to
support participationcomplements WHOs perspective.
Occupational therapists and occupational therapyassistants
recognize that engagement in occupation occursin a variety of
contexts (cultural, physical, social, person-al, temporal,
spiritual, virtual). They also recognize thatthe individuals
experience and performance cannot beunderstood or addressed without
understanding the manycontexts in which occupations and daily life
activitiesoccur.
Performance in Areas of Occupation
Occupational therapists and occupational therapy
assistantsdirect their expertise to the broad range of human
occupa-tions and activities that make up peoples lives. When
occu-pational therapists and assistants work with an individual,
agroup, or a population to promote engagement in occupa-tions and
in daily life activities, they take into account all ofthe many
types of occupations in which any individual,group, or population
might engage. These human activitiesare sorted into categories
called areas of occupationactivities of daily living, instrumental
activities of daily liv-ing, education, work, play, leisure, and
social participation(see Appendix, Table 1). Occupational
therapists and occu-pational therapy assistants under the
supervision of anoccupational therapist use their expertise to
address perfor-mance issues in any or all areas that are affecting
the personsability to engage in occupations and in
activities.Addressing performance issues in areas of
occupationrequires knowledge of what performance skills are
neededand what performance patterns are used.
Performance Skills
Skills are small units of performance. They are features ofwhat
one does (e.g., bends, chooses, gazes), versus underly-ing
capacities or body functions (e.g., joint mobility, moti-vation,
visual acuity). Skills are observable elements ofaction that have
implicit functional purposes (Fisher &Kielhofner, 1995, p.
113). For example, when observing aperson writing out a check, you
would notice skills of grip-ping and manipulating objects and
initiating and sequenc-ing the steps of the activity to complete
the writing of thecheck.
Execution of a performance skill occurs when the per-former, the
context, and the demands of the activity cometogether in the
performance of the activity. Each of these
factors influences the execution of a skill and may supportor
hinder actual skill execution.
When occupational therapists and occupational therapyassistants,
who have established competency under thesupervision of
occupational therapists, analyze performance,they specifically
identify the skills that are effective or inef-fective during
performance. They use skilled observationsand selected assessments
to evaluate the following skills: Motor skillsobserved as the
client moves and interacts
with task objects and environments. Aspects of motor
skillinclude posture, mobility, coordination, strength andeffort,
and energy. Examples of specific motor perfor-mance skills include
stabilizing the body, bending, andmanipulating objects.
Process skillsobserved as the client manages and modi-fies
actions while completing a task. Aspects of processskill include
energy, knowledge, temporal organization,organizing space and
objects, and adaptation. Examples ofspecific process performance
skills include maintainingattention to a task, choosing appropriate
tools and mate-rials for the task, logically organizing workspace,
oraccommodating the method of task completion inresponse to a
problem.
Communication/Interaction skillsobserved as the clientconveys
his or her intentions and needs and coordinatessocial behavior to
act together with people. Aspects ofcommunication/interaction
skills include physicality,information exchange, and relations.
Examples of specificcommunication/interaction performance skills
includegesturing to indicate intention, asking for
information,expressing affect, or relating in a manner to establish
rap-port with others.
Skilled performance (i.e., effective execution of perfor-mance
skills) depends on client factors (body functions,body structures),
activity demands, and the context.However, the presence of
underlying client factors (bodyfunctions and structures) does not
inherently ensure theeffective execution of performance skills.
(See Appendix,Table 2, for complete list of performance skills)
Performance Patterns
Performance patterns refer to habits, routines, and roles
thatare adopted by an individual as he or she carries out
occu-pations or daily life activities. Habits refer to specific,
auto-matic behaviors, whereas routines are established sequencesof
occupations or activities that provide a structure for dailylife.
Roles are a set of behaviors that have some sociallyagreed upon
function and for which there is an acceptedcode of norms
(Christiansen & Baum, 1997, p. 603).
Performance patterns develop over time and are influ-enced by
context (See Appendix, Table 3).
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Context
Context refers to a variety of interrelated conditions withinand
surrounding the client that influence performance.These contexts
can be cultural, physical, social, personal,spiritual, temporal,
and virtual. Some contexts are externalto the client (e.g.,
physical context, social context, virtualcontext); some are
internal to the client (e.g., personal, spir-itual); and some may
have external features, with beliefs andvalues that have been
internalized (e.g., cultural). Contextsmay include time dimensions
(e.g., within a temporal con-text, the time of day; within a
personal context, ones age)and space dimensions (e.g., within a
physical context, thesize of room in which activity occurs). When
the occupa-tional therapist and occupational therapy assistant
areattempting to understand performance skills and patterns,they
consider the specific contexts that surround the per-formance of a
particular occupation or activity. In this pro-cess, the therapist
and assistant consider all the relevant con-texts, keeping in mind
that some of them may not beinfluencing the particular skills and
patterns beingaddressed. (See Appendix, Table 4, for a description
of thedifferent kinds of contexts that occupational therapists
andoccupational therapy assistants consider.)
Activity Demands
The demands of the activity in which a person engages willaffect
skill and eventual success of performance.Occupational therapists
and occupational therapy assistantsapply their analysis skills to
determine the demands that anactivity will place on any performer
and how thosedemands will influence skill execution. (See
Appendix,Table 5, for complete list of activity demands.)
Client Factors
Performance can be influenced by factors that reside withinthe
client. Occupational therapists and occupational thera-py
assistants are knowledgeable about the variety of physi-cal,
cognitive, and psychosocial client factors that
influencedevelopment and performance and how illness, disease,
anddisability affect these factors. The occupational therapistand
occupational therapy assistant recognize that client fac-tors
influence the ability to engage in occupations and thatengagement
in occupations can also influence client factors.They apply their
understanding of this interaction and useit throughout the
intervention process.
Client factors include the following: Body
functionsphysiological function of body systems
(including psychological functions) (WHO, 2001, p.10). (See
Appendix, Table 6, for complete list.) The occu-pational therapist
and occupational therapy assistantunder the supervision of an
occupational therapist use
knowledge about body functions to evaluate selectedclient body
functions that may be affecting his or her abil-ity to engage in
desired occupations or activities.
Body structuresanatomical parts of the body such asorgans,
limbs, and their components (WHO, 2001, p.10). (See Appendix, Table
6.) Occupational therapists andoccupational therapy assistants
under the supervision ofan occupational therapist apply their
knowledge aboutbody structures to determine which body structures
areneeded to carry out an occupation or activity.
The categorization of client factors outlined in Table 6is based
on the International Classification of Functioning,Disability and
Health proposed by the WHO (2001). Theclassification was selected
because it has received wide expo-sure and presents a common
language that is understood byexternal audiences. The categories
include all those areasthat occupational therapists and assistants
address and con-sider during evaluation and intervention.
ProcessThe Process of Occupational Therapy: Evaluation,
Intervention, and Outcome
Many professions use the process of evaluating, intervening,and
targeting intervention outcomes that is outlined in theFramework.
However occupational therapys focus on occu-pation throughout the
process makes the professions appli-cation and use of the process
unique. The process of occu-pational therapy service delivery
begins by evaluating theclients occupational needs, problems, and
concerns.Understanding the client as an occupational human beingfor
whom access and participation in meaningful and pro-ductive
activities is central to health and well-being is a per-spective
that is unique to occupational therapy. Problemsand concerns that
are addressed in evaluation and interven-tion are also framed
uniquely from an occupational per-spective, are based on
occupational therapy theories, and aredefined as problems or risks
in occupational performance.During intervention, the focus remains
on occupation, andefforts are directed toward fostering improved
engagementin occupations. A variety of therapeutic activities,
includingengagement in actual occupations and in daily life
activities,are used in intervention.
Framework Process Organization
The Occupational Therapy Practice Framework process is
orga-nized into three broad sections that describe the process
ofservice delivery. A brief overview of the process as it is
appliedwithin the professions domain is outlined in Figure 2.
Figure 3 schematically illustrates how these sections arerelated
to one another and how they revolve around the col-
The American Journal of Occupational Therapy 613
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laborative therapeutic relationship between the client andthe
occupational therapist and occupational therapy assis-tant.
To help the reader understand the process, key state-ments
highlight important points about the process out-lined below.
The process outlined is dynamic and interactive innature.
Although the parts of the Framework are describedin a linear
manner, in reality, the process does not occur ina sequenced,
step-by-step fashion. The arrows in Figure 3that connect the boxes
indicate the interactive and nonlin-ear nature of the process. The
process, however, does alwaysstart with the occupational profile.
An understanding of theclients concerns, problems, and risks is the
cornerstone ofthe process. The factors that influence occupational
perfor-mance (performance skills, performance patterns, contextor
contexts, activity demands, client factors) continuallyinteract
with one another. Because of their dynamic inter-action, these
factors are frequently evaluated simultaneous-ly throughout the
process as their influence on performanceis observed.
Context is an overarching, underlying, embeddedinfluence on the
process of service delivery. Contextsexist around and within the
person. They influence boththe clients performance and the process
of delivering ser-vices. The external context (e.g., the physical
setting, socialand virtual contexts) provide resources that support
orinhibit the clients performance (e.g., presence of a
willingcaregiver) as well as the delivery of services (e.g.,
limitsplaced on length of intervention in an inpatient
hospitalsetting). Different settings (i.e., community,
institution,home) provide different supports and resources for
service
delivery. The clients internal context (personal and spiritu-al
contexts) affects service delivery by influencing personalbeliefs,
perceptions, and expectations. The cultural context,which exists
outside of the person but is internalized by theperson, also sets
expectations, beliefs, and customs that canaffect how and when
services may be delivered. Note that inFigure 3, context is
depicted as surrounding and underlyingthe process.
The term client is used to name the entity thatreceives
occupational therapy services. Clients may be
614 November/December 2002, Volume 56, Number 6
n Evaluation
Occupational profileThe initial step in the evaluation process
that provides an understanding of the clients occupational history
and experiences, patterns of dailyliving, interests, values, and
needs. The clients problems and concerns about performing
occupations and daily life activities are identified, and the
clients prioritiesare determined.
Analysis of occupational performanceThe step in the evaluation
process during which the clients assets, problems, or potential
problems are more specificallyidentified. Actual performance is
often observed in context to identify what supports performance and
what hinders performance. Performance skills, performance patterns,
context or contexts, activity demands, and client factors are all
considered, but only selected aspects may be specifically assessed.
Targeted outcomes areidentified.
n Intervention
Intervention planA plan that will guide actions taken and that
is developed in collaboration with the client. It is based on
selected theories, frames of reference,and evidence. Outcomes to be
targeted are confirmed.
Intervention implementationOngoing actions taken to influence
and support improved client performance. Interventions are directed
at identified outcomes.Clients response is monitored and
documented.
Intervention reviewA review of the implementation plan and
process as well as its progress toward targeted outcomes.n Outcomes
(Engagement in Occupation To Support Participation)
OutcomesDetermination of success in reaching desired targeted
outcomes. Outcome assessment information is used to plan future
actions with the client and toevaluate the service program (i.e.,
program evaluation).
Figure 2. Framework Process of Service Delivery as Applied
Within the Professions Domain.
INTERVENTION
Figure 3. Framework Collaborative Process Model. Illustration
ofthe framework emphasizing clientpractitioner interactive
relationshipand interactive nature of the service delivery
process.
OUTCOMES
CollaborativeProcess Between
Practitioner and Client
OccupationalProfile
Analysis ofOccupationalPerformance
Intervention Plan
InterventionImplementation
InterventionReview
Engagement inOccupation to Support
Participation
EVALUATION
CONTEXT
CONTEXT
CONTEXT
CONTEXT
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categorized as (a) individuals, including individuals whomay be
involved in supporting or caring for the client (i.e.,caregiver,
teacher, parent, employer, spouse); (b) individu-als within the
context of a group (i.e., a family, a class); or(c) individuals
within the context of a population (i.e., anorganization, a
community). The definition of client isconsistent with The Guide to
Occupational Therapy Practice(Moyers, 1999) and is indicative of
the professions grow-ing understanding that people may be served
not only asindividuals, but also as members of a group or a
popula-tion. The actual term used for individuals who are
servedwill vary by practice setting. For example, in a hospital,
theperson might be referred to as a patient, whereas in aschool, he
or she might be called a student. Clients maybe served as
individuals, groups, or populations. Althoughthe most common form
of service delivery within the pro-fession now involves a direct
individual client to serviceprovider model, more and more
occupational therapistsand occupational therapy assistants are
beginning to serveclients at the group and population level (i.e.,
organization,community). When providing interventions other than
ina one-to-one model, the occupational therapist and occu-pational
therapist assistant are seen as agents who help oth-ers to support
client engagement in occupations ratherthan as those who personally
provide that support. Often,they use education and consultation as
interventions.When occupational therapists and occupational
therapyassistants are collaborating with clients to provide
servicesat the group or population level, an important point to
rec-ognize is that although interventions may be directed to agroup
or population (i.e., organization, community), theindividuals
within those entities are the ones who are beingevaluated and
served. The wants, needs, occupational risksor problems, and
performance patterns and skills of indi-viduals within the group or
population (i.e., organization,community) are evaluated as an
aggregate, and informa-tion is compiled to determine group or
population occu-pational issues and solutions.
A client-centered approach is used throughout theFramework. The
Framework incorporates the value ofclient-centered evaluation and
intervention by recognizingfrom the outset that all interventions
must be focused onclient priorities. The very nature of engagement
in occupa-tionwhich is internally motivated, is individually
defined,and requires active participation by the clientmeans
thatthe client must be an active participant in the process.Clients
identify what occupations and activities are impor-tant to them and
determine the degree of engagement ineach occupation. However, in
some circumstances theclients ability to provide a description of
the perceived ordesired occupations or activity may be limited
because of
either the nature of the clients problems (e.g.,
autism,dementia) or the stage of development (e.g., infants).
Whenthis occurs, the occupational therapist and occupationaltherapy
assistant must then take a broader view of the clientand seek input
from others such as family or significant oth-ers who would have
knowledge and insight into the clientsdesires. By involving the
family or significant others, theoccupational therapist and
assistant can better understandthe clients history, developmental
stage, and current con-texts. Inclusion of others in these
circumstances allows theclient to be represented in intervention
planning and imple-mentation.
The entire process of service delivery begins with a
col-laborative relationship with the client. The
collaborativerelationship continues throughout the process and
affectsall phases of the process. The central importance of this
col-laboration is noted in Figure 3.
The Framework is based on the belief that the occu-pational
therapist, occupational therapy assistant, and theclient bring
unique resources to the Framework process.Occupational therapists
and occupational therapy assis-tants bring knowledge about how
engagement in occupa-tion affects health and performance. They also
bringknowledge about disease and disability and couple
thisinformation with their clinical reasoning and
theoreticalperspectives to critically observe, analyze, describe,
andinterpret human performance. Therapists and assistantscombine
their knowledge and skills to modify the factorsthat influence
engagement in occupation to improve andsupport performance. Clients
bring knowledge about theirlife experiences and their hopes and
dreams for the future.Clients share their priorities, which are
based on what isimportant to them, and collaborate with the
therapist andassistant in directing the intervention process to
those pri-orities.
Engagement in occupation is viewed as the over-arching outcome
of the occupational therapy process.The Framework emphasizes
occupational therapys uniquecontribution to health by identifying
engagement in occu-pation to support participation as the end
objective of theoccupational therapy process. The profession
recognizesthat in some areas of practice (e.g., acute
rehabilitation,hand therapy) occupational therapy intervention may
focusprimarily on performance skills or on client factors
(i.e.,body functions, body structures) that will enable engage-ment
in occupations later in the continuum of care.
Evaluation Process
The evaluation process sets the stage for all that
follows.Because occupational therapy is concerned with perfor-mance
in daily life and how performance affects engage-
The American Journal of Occupational Therapy 615
-
ment in occupations to support participation, the evalua-tion
process is focused on finding out what the client wantsand needs to
do and on identifying those factors that act assupports or barriers
to performance. During the evaluationprocess, this information is
paired with the occupationaltherapists knowledge about human
performance and theeffect that illness, disability, and engagement
in occupationhave on performance. The occupational therapist
considersperformance skills, performance patterns, context,
activitydemands, and client factors and determines how each
influ-ences performance. The occupational therapists
skilledobservation, use of specific assessments, and
interpretationof results leads to a clear delineation of the
problems andprobable causes. The occupational therapy assistant
maycontribute to the evaluation process based on
establishedcompetencies and under the supervision of an
occupation-al therapist.
During the evaluation, a collaborative relationship withthe
client is established that continues throughout theentire
occupational therapy process. The evaluation processis divided into
two substeps, the first of which is the occu-pational profilethe
initial step during which the clientsneeds, problems, and concerns
about occupations and dailylife activity performance are identified
and priorities andvalues ascertained. The clients background and
history inreference to engagement in occupations and in activities
arealso explored. The second substep of the evaluation
process,analysis of occupational performance, focuses on
morespecifically identifying occupational performance issues
andevaluating selected factors that support and hinder
perfor-mance. Although each subsection is described separatelyand
sequentially, in actuality, information pertinent to
bothsubsections may be gathered during either one. The clientsinput
is central in this process, and the clients prioritiesguide choices
and decisions made during the process ofevaluation.
Occupational Profile
An occupational profile is defined as information thatdescribes
the clients occupational history and experiences,patterns of daily
living, interests, values, and needs. Theprofile is designed to
gain an understanding of the clientsperspective and background.
Using a client-centeredapproach, information is gathered to
understand what iscurrently important and meaningful to the client
(what heor she wants and needs to do) and to identify past
experi-ences and interests that may assist in the understanding
ofcurrent issues and problems. During the process of collect-ing
this information, the clients priorities and desired tar-geted
outcomes that will lead to engagement in occupationto support
participation in life are also identified. Only
clients can identify the occupations that give meaning totheir
lives and select the goals and priorities that are impor-tant to
them. Valuing and respecting the clients input helpsto foster
client involvement and can more efficiently guideinterventions.
Information about the occupational profile is collectedat the
beginning of contact with the client. However, addi-tional
information is collected over time throughout theprocess, refined,
and reflected in changes subsequentlymade to targeted outcomes.
Process. The theories and frames of reference that
theoccupational therapist selects to guide his or her reasoningwill
influence the information that is collected during theoccupational
profile. Scientific knowledge and evidenceabout diagnostic
conditions and occupational performanceproblems is used to guide
information gathering.
The process of completing the occupational profilewill vary
depending on the setting and the client. Theinformation gathered in
the profile may be obtained bothformally and informally and may be
completed in one ses-sion or over a much longer period while
working with theclient. Obtaining information through both formal
inter-view and casual conversation is a way of beginning
toestablish a therapeutic relationship with the client. Ideally,the
information obtained through the occupational profilewill lead to a
more individualized approach in the evalua-tion, intervention
planning, and intervention implementa-tion stages.
Specifically, the following information is collected: Who is the
client (individual, caregiver, group, popula-
tion)? Why is the client seeking service, and what are the
clients
current concerns relative to engaging in occupations andin daily
life activities?
What areas of occupation are successful, and what areasare
causing problems or risks? (see Figure 1)
What contexts support engagement in desired occupa-tions, and
what contexts are inhibiting engagement?
What is the clients occupational history (i.e., life
experi-ences, values, interests, previous patterns of engagementin
occupations and in daily life activities, the meaningsassociated
with them)?
What are the clients priorities and desired targeted out-comes
(see Appendix, Table 9)? Occupational performance Client
satisfaction Role competence Adaptation Health and wellness
Prevention Quality of life
616 November/December 2002, Volume 56, Number 6
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After profile data are collected, the therapist reviews
theinformation and develops a working hypothesis regardingpossible
reasons for identified problems and concerns andidentifies the
clients strengths and weaknesses. Outcomemeasures are preliminarily
selected.
Analysis of Occupational Performance
Occupational performance is defined as the ability to carryout
activities of daily life, including activities in the areas
ofoccupation: activities of daily living (ADL) [also called
basicactivities of daily living (BADL) and personal activities
ofdaily living (PADL)], instrumental activities of daily
living(IADL), education, work, play, leisure, and social
participa-tion. Occupational performance results in the
accomplish-ment of the selected occupation or activity and occurs
througha dynamic transaction among the client, the context, and
theactivity. Improving or developing skills and patterns in
occu-pational performance leads to engagement in one or
moreoccupations (adapted in part from Law et al., 1996, p. 16).
When occupational performance is analyzed, the per-formance
skills and patterns used in performance are iden-tified, and other
aspects of engaging in occupation thataffect skills and patterns
(e.g., client factors, activitydemands, context or contexts) are
evaluated. The analysisprocess identifies facilitators as well as
barriers in variousaspects of engagement in occupations and in
daily life activ-ities. Analyzing occupational performance requires
anunderstanding of the complex and dynamic interactionamong
performance skills, performance patterns, context orcontexts,
activity demands, and client factors rather than ofany one factor
alone.
The information gathered during the occupational pro-file about
the clients needs, problems, and priorities guidesdecisions during
the analysis of occupational performance.The profile information
directs the therapists selection ofthe specific occupations or
activities that need to be furtheranalyzed and influences the
selection of specific assessmentsthat are used during the analysis
process.
Process. Using available evidence and all aspects of clin-ical
reasoning (scientific, narrative, pragmatic, ethical), thetherapist
selects one or more frames of reference to guidefurther collection
of evaluation information. The followingactions are taken:
Synthesize information from the occupational profile to
focus on specific areas of occupation and their contextsthat
need to be addressed.
Observe the clients performance in desired occupationsand
activities, noting effectiveness of the performanceskills and
performance patterns. May select and use spe-cific assessments to
measure performance skills and pat-terns as appropriate.
Select assessments, as needed, to identify and measuremore
specifically context or contexts, activity demands,and client
factors that may be influencing performanceskills and performance
patterns.
Interpret the assessment data to identify what
supportsperformance and what hinders performance.
Develop and refine hypotheses about the clients occupa-tional
performance strengths and weaknesses.
Create goals in collaboration with the client that addressthe
desired targeted outcomes. Confirm outcome measureto be used.
Delineate potential intervention approach or approachesbased on
best practice and evidence.
Intervention Process
The intervention process is divided into three
substeps:intervention plan, intervention implementation, and
inter-vention review. During the intervention process, informa-tion
from the evaluation step is integrated with theory,frames of
reference, and evidence and is coupled with clin-ical reasoning to
develop a plan and carry it out. The planguides the actions of the
occupational therapist and occu-pational therapy assistant and is
based on the clients prior-ities. Interventions are carried out to
address performanceskills, patterns, context or contexts, activity
demands, andclient factors that are hindering performance.
Periodicreviews throughout the process allow for revisions in
theplan and actions. Again, collaboration with the client is
vitalin this section of the process to ensure effectiveness and
suc-cess. All interventions are ultimately directed toward
achiev-ing the overarching outcome of engagement in occupationto
support participation.
Intervention Plan
An intervention plan is defined as a plan that is developedbased
on the results of the evaluation process and describesselected
occupational therapy approaches and types of inter-ventions to
reach the clients identified targeted outcomes.An intervention plan
is developed collaboratively with theclient (including, in some
cases, family or significant others)and is based on the clients
goals and priorities.
The design of the intervention plan is directed by the clients
goals, values, and beliefs; the health and well-being of the
client; the clients performance skills and performance
patterns,
as they are influenced by the interaction among the con-text or
contexts, activity demands, and client factors;and
the setting or circumstance in which the intervention isprovided
(e.g., caregiver expectations, organizations pur-pose, payers
requirements, or applicable regulations).
The American Journal of Occupational Therapy 617
-
Interventions are designed to foster engagement inoccupations
and in activities to support participation in life.The selection
and design of the intervention plan and goalsare directed toward
addressing the clients current andpotential problems related to
engagement in occupations orin activities.
Process. Intervention planning includes the followingsteps:1.
Develop the plan. The occupational therapist develops
the plan. The occupational therapy assistant, based
onestablished competencies and under the supervision ofthe
occupational therapist, may contribute to the plansdevelopment. The
plan includes the following:
Objective and measurable goals with a timeframe Occupational
therapy intervention approach or
approaches based on theory and evidence (seeAppendix, Table 7).
Create or promote Establish or restore Maintain Modify Prevent
Mechanisms for service delivery Who will provide intervention
Types of interventions Frequency and duration of service
2. Consider potential discharge needs and plans.3. Select
outcome measures.4. Make recommendation or referral to others as
needed.
Intervention Implementation
Intervention is the process of putting the plan into
action.Intervention implementation is defined as the skilled
pro-cess of effecting change in the clients occupational
perfor-mance, leading to engagement in occupations or in
activi-ties to support participation. Intervention implementationis
a collaborative process between the client and the occu-pational
therapist and assistant.
Interventions may be focused on changing the contextor contexts,
activity demands, client factors, performanceskills, or performance
patterns. Occupational therapists andoccupational therapy
assistants recognize that change in onefactor may influence other
factors. All factors that affectperformance are interrelated and
influence one another in acontinuous dynamic process that results
in performance indesired areas of occupation. Because of this
dynamic inter-relationship, dynamic assessment continues throughout
theimplementation process.
Process. Intervention implementation includes the fol-lowing
steps:1. Determine and carry out the type of occupational ther-
apy intervention or interventions to be used (seeAppendix, Table
8).
Therapeutic use of self Therapeutic use of occupations or
activities
Occupation-based activity Purposeful activity Preparatory
methods
Consultation process Education process
2. Monitor clients response to interventions based onongoing
assessment and reassessment.
Intervention Review
Intervention review is defined as a continuous process
forreevaluating and reviewing the intervention plan, the
effec-tiveness of its delivery, and the progress toward targeted
out-comes. This process includes collaboration with the
client(including, in some cases, family, significant others,
andother service providers). Reevaluation and review may leadto
change in the intervention plan. The intervention reviewprocess may
be carried out differently in a variety of settings.
Process. The intervention review includes the followingsteps:1.
Reevaluate the plan and how it is carried out with the
client relative to achieving targeted outcomes.2. Modify the
plan as needed.3. Determine the need for continuation,
discontinuation,
or referral.
Outcomes Process
Outcomes are defined as important dimensions of healththat are
attributed to interventions, including ability tofunction, health
perceptions, and satisfaction with care(adapted from Request for
Planning Ideas, 2001). Theimportant dimension of health that
occupational therapistsand occupational therapy assistants target
as the professionsoverarching outcome is engagement in occupation
to sup-port participation. The two concepts included in this
out-come are defined as follows: Engagement in occupationThe
commitment made to
performance in occupations or activities as the result
ofself-choice, motivation, and meaning, and includes theobjective
and subjective aspects of carrying out occupa-tions and activities
that are meaningful and purposefulto the person.
Participationinvolvement in a life situation (WHO,2001, p.
10).
Engagement in occupation to support participation isthe broad
outcome of intervention that is designed to fosterperformance in
desired and needed occupations or activities.When clients are
actively involved in carrying out occupa-
618 November/December 2002, Volume 56, Number 6
-
tions or daily life activities that they find purposeful
andmeaningful in home and community settings, participationis a
natural outcome. Less broad and more specific outcomesof
occupational therapy intervention (see Appendix, Table 9)are
multidimensional and support the end result of engage-ment in
occupation to support participation.
In targeting engagement in occupation to support par-ticipation
as the broad, overarching outcome of the occu-pational therapy
intervention process, the profession under-scores its belief that
health and well-being are holistic andthat they are developed and
maintained through activeengagement in occupation.
The focus on outcomes is interwoven throughout theprocess of
service delivery within occupational therapy.During the evaluation
phase of the process, the clients ini-tial targeted outcomes
regarding desired engagement inoccupation or daily life activities
are identified. As furtheranalysis of occupational performance and
development ofthe treatment plan take place, targeted outcomes are
furtherrefined. During intervention implementation and
reevalua-tion, targeted outcomes may be modified based on chang-ing
needs, contexts, and performance abilities. Outcomeshave numerous
definitions and connotations for differentclients, payers,
regulators, and organizations. The specificoutcomes chosen will
vary by practice setting and will beinfluenced by the particular
stakeholders in each setting.
Process. Implementation of the outcomes processincludes the
following steps:1. Select types of outcomes and measures,
including, but
not limited to occupational performance, client satisfac-tion,
adaptation, role competence, health and wellness,prevention, and
quality of life.
Selection of outcome measures occurs early in theintervention
process (see Evaluation Process,Occupational Profile section).
Outcome measures that are selected are valid, reliable,and
appropriately sensitive to change in the clientsoccupational
performance, and they match the tar-geted outcomes.
Selection of an outcome measure or instrument for aparticular
client should be congruent with client goals.
Selection of an outcome measure should entail con-sidering its
actual or purported ability to predictfuture outcomes.
2. Measure and use outcomes. Compare progress toward goal
achievement to target-
ed outcomes throughout the intervention process. Assess outcome
results and use to make decisions
about future direction of intervention (i.e.,
continueintervention, modify intervention, discontinue
inter-vention, provide follow-up, refer to other services).
An Overview of the Occupational Therapy Practice ProcessTable 10
in the Appendix summarizes the process thatoccurs during
occupational therapy service delivery. Thearrow placed between the
Occupational Profile andAnalysis of Occupational Performance
evaluation substepsindicates the interactions between these two.
However, asimilar interaction occurs among all of the steps and
sub-steps. The process is not linear but, instead, is fluid
anddynamic, allowing the occupational therapist and occupa-tional
therapy assistant to operate with an ongoing focuson outcomes while
continually reflecting and changing anoverall plan to accommodate
new developments andinsights along the way.
AcknowledgmentsThe Commission on Practice (COP) would like to
thankand acknowledge all those who participated in the reviewand
comment process associated with the development ofthe Occupational
Therapy Practice Framework: Domain andProcess. The COP has found
this process invaluable andenriching. Everyones input has been
carefully reviewedand considered. Often, small comments repeated by
manycan lead to significant discussion and change. The COPhopes
that all those who contributed to this process willcontinue to do
so for future documents and will encourageothers to participate.
The profession is richer for this process.
The COP would like to thank the following individu-als for their
significant contributions to the direction andfinal content of this
document: Carolyn Baum, PhD, OTR,FAOTA; Elizabeth Crepeau, PhD,
OTR, FAOTA; Patricia A.Crist, PhD, FAOTA; Winifred Dunn, PhD, OTR,
FAOTA;Anne G. Fisher, PhD, OTR, FAOTA; Gail S. Fidler, OTR,FAOTA;
Mary Foto, OT, FAOTA; Nedra Gillette, SCD (HON),MEd, OTR, FAOTA;
Jim Hinojosa, PhD, OT, FAOTA; Margo B.Holm, PhD, OTR, FAOTA; Gary
Kielhofner, DRPH, OTR/L,FAOTA; Paula Kramer, PhD, OTR, FAOTA; Mary
Law, PhD,OT(C); Linda T. Learnard, OTR/L; Anne Mosey, PhD,
OTR,FAOTA; Penelope A. Moyers, EDd, OTR, FAOTA; DavidNelson, PhD,
OTR, FAOTA; Marta Pelczarski, OTR; KathlynL. Reed, PhD, OTR, FAOTA;
Barbara Schell, PhD, OTR/L,FAOTA; Janette Schkade, PhD, OTR; Wendy
Schoen; CarolSiebert, MS, OTR/L; V. Judith Thomas, MGA;
LindaKohlman Thomson, MOT, OT, OT(C), FAOTA; Amy L.Walsh, OTR/L;
Wendy Wood, PhD, OTR, FAOTA; BostonUniversity OT Students mentored
by Karen Jacobs, EDd,OTR/L, CPE, FAOTA; and the University of
KansasOccupational Therapy Education Faculty.
The American Journal of Occupational Therapy 619
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620 November/December 2002, Volume 56, Number 6
Appendix
TABLE 1. AREAS OF OCCUPATION Various kinds of life activities in
which people engage, including ADL, IADL, education, work, play,
leisure, and social participation.
n ACTIVITIES OF DAILY LIVING (ADL)
Activities that are oriented toward taking care ofones own body
(adapted from Rogers & Holm,1994, pp. 181202)also called basic
activities ofdaily living (BADL) or personal activities of
dailyliving (PADL).
Bathing, showeringObtaining and using sup-plies; soaping,
rinsing, and drying body parts;maintaining bathing position; and
transferring toand from bathing positions.
Bowel and bladder management Includescomplete intentional
control of bowel movementsand urinary bladder and, if necessary,
use of equip-ment or agents for bladder control (Uniform DataSystem
for Medical Rehabilitation [UDSMR], 1996,pp. III20, III24).
DressingSelecting clothing and accessoriesappropriate to time of
day, weather, and occasion;obtaining clothing from storage area;
dressing andundressing in a sequential fashion; fastening
andadjusting clothing and shoes; and applying andremoving personal
devices, prostheses, ororthoses.
EatingThe ability to keep and manipulatefood/fluid in the mouth
and swallow it (OSullivan,1995, p. 191) (AOTA, 2000, p. 629).
FeedingThe process of [setting up, arranging,and] bringing food
[fluids] from the plate or cup tothe mouth (OSullivan, 1995, p.
191) (AOTA, 2000,p. 629).
Functional mobilityMoving from one positionor place to another
(during performance of every-day activities), such as in-bed
mobility, wheelchairmobility, transfers (wheelchair, bed, car, tub,
toilet,tub/shower, chair, floor). Performing functionalambulation
and transporting objects.
Personal device careUsing, cleaning, andmaintaining personal
care items, such as hearingaids, contact lenses, glasses,
orthotics, prosthetics,adaptive equipment, and contraceptive and
sexualdevices.
Personal hygiene and groomingObtainingand using supplies;
removing body hair (use ofrazors, tweezers, lotions, etc.);
applying and remov-ing cosmetics; washing, drying, combing,
styling,brushing, and trimming hair; caring for nails(hands and
feet); caring for skin, ears, eyes, andnose; applying deodorant;
cleaning mouth; brush-ing and flossing teeth; or removing,
cleaning, andreinserting dental orthotics and prosthetics.
Sexual activityEngagement in activities thatresult in sexual
satisfaction.
Sleep/restA period of inactivity in which onemay or may not
suspend consciousness.
Toilet hygieneObtaining and using supplies;clothing management;
maintaining toileting posi-tion; transferring to and from toileting
position;cleaning body; and caring for menstrual and conti-nence
needs (including catheters, colostomies, andsuppository
management).
n INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)
Activities that are oriented toward interacting withthe
environment and that are often complexgenerally optional in nature
(i.e., may be delegatedto another) (adapted from Rogers & Holm,
1994,pp. 181202).
Care of others (including selecting andsupervising
caregivers)Arranging, supervis-ing, or providing the care for
others.
Care of petsArranging, supervising, or provid-ing the care for
pets and service animals.
Child rearingProviding the care and super-vision to support the
developmental needs of achild.
Communication device useUsing equipmentor systems such as
writing equipment, telephones,typewriters, computers, communication
boards, calllights, emergency systems, braille writers,
telecom-munication devices for the deaf, and
augmentativecommunication systems to send and receive
infor-mation.
Community mobilityMoving self in the com-munity and using public
or private transportation,such as driving, or accessing buses, taxi
cabs, orother public transportation systems.
Financial managementUsing fiscalresources, including alternate
methods of financialtransaction and planning and using finances
withlong-term and short-term goals.
Health management and maintenanceDeveloping, managing, and
maintaining routinesfor health and wellness promotion, such as
physi-cal fitness, nutrition, decreasing health risk behav-iors,
and medication routines.
Home establishment and managementObtaining and maintaining
personal and householdpossessions and environment (e.g., home,
yard,garden, appliances, vehicles), including maintain-ing and
repairing personal possessions (clothingand household items) and
knowing how to seekhelp or whom to contact.
Meal preparation and cleanupPlanning,preparing, serving
well-balanced, nutritional mealsand cleaning up food and utensils
after meals.
Safety procedures and emergency responsesKnowing and performing
preventiveprocedures to maintain a safe environment as wellas
recognizing sudden, unexpected hazardous situ-ations and initiating
emergency action to reduce thethreat to health and safety.
ShoppingPreparing shopping lists (grocery andother); selecting
and purchasing items; selectingmethod of payment; and completing
money trans-actions.
n EDUCATION
Includes activities needed for being a student andparticipating
in a learning environment.
Formal educational participationIncludingthe categories of
academic (e.g., math, reading,working on a degree), nonacademic
(e.g., recess,lunchroom, hallway), extracurricular (e.g.,
sports,band, cheerleading, dances), and vocational (pre-vocational
and vocational) participation.
Exploration of informal personal educational needs or interests
(beyond formal education)Identifying topics and meth-ods for
obtaining topic-related information or skills.
Informal personal education participationParticipating in
classes, programs, and activitiesthat provide instruction/training
in identified areasof interest.
n WORK
Includes activities needed for engaging in remunerative
employment or volunteer activities(Mosey, 1996, p. 341).
Employment interests and pursuitsIdentifying and selecting work
opportunities basedon personal assets, limitations, likes, and
dislikesrelative to work (adapted from Mosey, 1996, p. 342).
Employment seeking and acquisitionIdentifying job opportunities,
completing and submitting appropriate application
materials,preparing for interviews, participating in interviewsand
following up afterward, discussing job benefits,and finalizing
negotiations.
Job performanceIncluding work habits, forexample, attendance,
punctuality, appropriate relationships with coworkers and
supervisors, completion of assigned work, and compliance withthe
norms of the work setting (adapted from Mosey,1996, p. 342).
Retirement preparation and adjustmentDetermining aptitudes,
developing interests andskills, and selecting appropriate
avocational pursuits.
(Continued)
-
The American Journal of Occupational Therapy 621
Volunteer explorationDetermining community causes,
organizations, or opportunitiesfor unpaid work in relationship to
personal skills,interests, location, and time available.
Volunteer participationPerforming unpaidwork activities for the
benefit of identified selectedcauses, organizations, or
facilities.
n PLAY
Any spontaneous or organized activity that provides enjoyment,
entertainment, amusement, ordiversion (Parham & Fazio, 1997, p.
252).
Play explorationIdentifying appropriate playactivities, which
can include exploration play, practice play, pretend play, games
with rules, constructive play, and symbolic play (adapted
fromBergen, 1988, pp. 6465).
Play participationParticipating in play; main-taining a balance
of play with other areas of occu-pation; and obtaining, using, and
maintaining, toys,equipment, and supplies appropriately.
n LEISURE
A nonobligatory activity that is intrinsically motivat-ed and
engaged in during discretionary time, that is,time not committed to
obligatory occupations suchas work, self-care, or sleep (Parham
& Fazio, 1997,p. 250).
Leisure explorationIdentifying interests,skills, opportunities,
and appropriate leisure activities.
Leisure participationPlanning and partici-pating in appropriate
leisure activities; maintaininga balance of leisure activities with
other areas ofoccupation; and obtaining, using, and
maintainingequipment and supplies as appropriate.
n SOCIAL PARTICIPATION
Activities associated with organized patterns ofbehavior that
are characteristic and expected of anindividual or an individual
interacting with otherswithin a given social system (adapted from
Mosey,1996, p. 340).
CommunityActivities that result in successfulinteraction at the
community level (i.e., neighbor-hood, organizations, work,
school).
Family[Activities that result in] successfulinteraction in
specific required and/or desiredfamilial roles (Mosey, 1996, p.
340).
Peer, friendActivities at different levels of inti-macy,
including engaging in desired sexual activity.
TABLE 1. AREAS OF OCCUPATION (Continued)
Note. Some of the terms used in this table are from, or adapted
from, the rescinded Uniform Terminology for Occupational
TherapyThird Edition (AOTA, 1994, pp. 10471054).
TABLE 2. PERFORMANCE SKILLSFeatures of what one does, not what
one has, related to observable elements of action that have
implicit functional purposes (adapted from Fisher & Kielhofner,
1995, p. 113).
n MOTOR SKILLSskills in moving and interacting with task,
objects, and environment (A. Fisher, personal communication, July
9, 2001).
PostureRelates to the stabilizing and aligning ofones body while
moving in relation to task objectswith which one must deal.
StabilizesMaintains trunk control and balancewhile interacting
with task objects such that there isno evidence of transient (i.e.,
quickly passing) prop-ping or loss of balance that affects task
performance.
AlignsMaintains an upright sitting or standingposition, without
evidence of a need to persistentlyprop during the task
performance.
PositionsPositions body, arms, or wheelchair in relation to task
objects and in a manner that promotes the use of efficient arm
movements duringtask performance.
MobilityRelates to moving the entire body or abody part in space
as necessary when interactingwith task objects.
WalksAmbulates on level surfaces and changesdirection while
walking without shuffling the feet,lurching, instability, or using
external supports orassistive devices (e.g., cane, walker,
wheelchair)during the task performance.
ReachesExtends, moves the arm (and whenappropriate, the trunk)
to effectively grasp or placetask objects that are out of reach,
including skillfullyusing a reacher to obtain task objects.
BendsActively flexes, rotates, or twists the trunkin a manner
and direction appropriate to the task.
CoordinationRelates to using more than onebody part to interact
with task objects in a mannerthat supports task performance.
CoordinatesUses two or more body parts togetherto stabilize and
manipulate task objects during bilateral motor tasks.
ManipulatesUses dexterous grasp-and-releasepatterns, isolated
finger movements, and coordinat-ed in-hand manipulation patterns
when interactingwith task objects.
FlowsUses smooth and fluid arm and handmovements when
interacting with task objects.
Strength and effortPertains to skills thatrequire generation of
muscle force appropriate foreffective interaction with task
objects.
MovesPushes, pulls, or drags task objects alonga supporting
surface.
TransportsCarries task objects from one place toanother while
walking, seated in a wheelchair, orusing a walker.
LiftsRaises or hoists task objects, including liftingan object
from one place to another, but withoutambulating or moving from one
place to another.
CalibratesRegulates or grades the force, speed,and extent of
movement when interacting with taskobjects (e.g., not too much or
too little).
GripsPinches or grasps task objects with no gripslips.
EnergyRefers to sustained effort over the courseof task
performance.
EnduresPersists and completes the task withoutobvious evidence
of physical fatigue, pausing torest, or stopping to catch ones
breath.
PacesMaintains a consistent and effective rate ortempo of
performance throughout the steps of theentire task.
n PROCESS SKILLSSkillsused in managingand modifying actions en
route to the completion ofdaily life tasks (Fisher &
Kielhofner, 1995, p. 120).
EnergyRefers to sustained effort over the courseof task
performance.
PacesMaintains a consistent and effective rate ortempo of
performance throughout the steps of theentire task.
(Continued)
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622 November/December 2002, Volume 56, Number 6
AttendsMaintains focused attention throughoutthe task such that
the client is not distracted awayfrom the task by extraneous
auditory or visual stimuli.
KnowledgeRefers to the ability to seek and usetask-related
knowledge.
ChoosesSelects appropriate and necessary toolsand materials for
the task, including choosing thetools and materials that were
specified for use priorto the initiation of the task.
UsesUses tools and materials according to theirintended purposes
and in a reasonable or hygienicfashion, given their intrinsic
properties and the avail-ability (or lack of availability) of other
objects.
HandlesSupports, stabilizes, and holds tools andmaterials in an
appropriate manner that protectsthem from damage, falling, or
dropping.
HeedsUses goal-directed task actions that arefocused toward the
completion of the specified task(i.e., the outcome originally
agreed on or specifiedby another) without behavior that is driven
or guidedby environmental cues (i.e., environmentally
cuedbehavior).
Inquires(a) Seeks needed verbal or written infor-mation by
asking questions or reading directions orlabels or (b) asks no
unnecessary information ques-tions (e.g., questions related to
where materials arelocated or how a familiar task is
performed).
Temporal organizationPertains to the begin-ning, logical
ordering, continuation, and completionof the steps and action
sequences of a task.
InitiatesStarts or begins the next action or stepwithout
hesitation.
ContinuesPerforms actions or action sequencesof steps without
unnecessary interruption such thatonce an action sequence is
initiated, the individualcontinues on until the step is
completed.
SequencesPerforms steps in an effective orlogical order for
efficient use of time and energy
and with an absence of (a) randomness in the ordering and/or (b)
inappropriate repetition(reordering) of steps.
TerminatesBrings to completion single actions orsingle steps
without perseveration, inappropriatepersistence, or premature
cessation.
Organizing space and objectsPertains toskills for organizing
task spaces and task objects.
Searches/locatesLooks for and locates tools andmaterials in a
logical manner, including lookingbeyond the immediate environment
(e.g., looking in,behind, on top of).
GathersCollects together needed or misplacedtools and materials,
including (a) collecting locatedsupplies into the workspace and (b)
collecting andreplacing materials that have spilled, fallen, or
beenmisplaced.
Accommodates to other peoples reactions and requests.
TABLE 2. PERFORMANCE SKILLS(Continued)
Note. The Motor and Process Skills sections of this table were
compiled from the following sources: Fisher (2001), Fisher and
Kielhofner (1995)updated by Fisher (2001).The
Communication/Interaction Skills section of this table was compiled
from the following sources: Forsyth and Kielhofner (1999), Forsyth,
Salamy, Simon, and Kielhofner(1997), and Kielhofner (2002).
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TABLE 3. PERFORMANCE PATTERNSPatterns of behavior related to
daily life activities that are habitual or routine.
n HABITSAutomatic behavior that is integrated into more complex
patterns that enable people to function on a day-to-day basis
(Neistadt & Crepeau, 1998, p. 869).Habits can either support or
interfere with performance in areas of occupation.
Type of Habit Examples
Useful habits
Habits that support performance in daily life and contribute to
life satisfaction. Always put car keys in the same place so they
can be found easily.
Habits that support ability to follow rhythms of daily life.
Brush teeth every morning to maintain good oral hygiene.
Impoverished habits
Habits that are not established. Inconsistently remembering to
look both ways before crossing the street.
Habits that need practice to improve. Inability to complete all
steps of a self-care routine.
Dominating habits
Habits that are so demanding they interfere with daily life.
Repetitive self-stimulation such as type occurring in autism. Use
of chemical substances, resulting in addiction.
Habits that satisfy a compulsive need for order. Neatly
arranging forks on top of each other in silverware drawer.
n ROUTINESOccupations with established sequences (Christiansen
& Baum, 1997, p. 6).
n ROLESA set of behaviors that have some socially agreed upon
function and for which there is an accepted code of norms
(Christiansen & Baum, 1997, p. 603).
Note. Information for Habits section of this table adapted from
Dunn (2000, Fall).
The American Journal of Occupational Therapy 623
TABLE 4. CONTEXT OR CONTEXTSContext (including cultural,
physical, social, personal, spiritual, temporal, and virtual)
refers to a variety of interrelated conditions within and
surrounding the clientthat influence performance.
Context Definition Example
Cultural Customs, beliefs, activity patterns, behavior
standards, and expectations accepted by the society of which the
individual is a member. Includes political aspects, such as laws
that affect access to resources and affirm personal rights. Also
includes opportunities for education, employment, and economic
support.
Physical Nonhuman aspects of contexts. Includes the
accessibility to and performance within environments having natural
terrain, plants, animals, buildings, furniture, objects, tools, or
devices.
Social Availability and expectations of significant individuals,
such as spouse, friends, and caregivers. Also includes larger
social groups that are influential in establishing norms, role
expectations, and social routines.
Personal [F]eatures of the individual that are not part of a
health condition or health status (WHO, 2001, p. 17). Personal
context includes age, gender, socioeconomic status, and educational
status.
Spiritual The fundamental orientation of a persons life; that
which inspires and motivates that individual.
Temporal Location of occupational performance in time (Neistadt
& Crepeau, 1998, p. 292).
Virtual Environment in which communication occurs by means of
airways or computers and an absence of physical contact.
Note. Some of the definitions for areas of context or contexts
are from the rescinded Uniform Terminology for Occupational
TherapyThird Edition (AOTA, 1994).
Ethnicity, family, attitude, beliefs, values
Objects, built environment, natural environment,
geographicterrain, sensory qualities of environment
Relationships with individuals, groups, or organizations;
relationships with systems (political, economic, institutional)
Twenty-five-year-old unemployed man with a high
schooldiploma
Essence of the person, greater or higher purpose,
meaning,substance
Stages of life, time of day, time of year, duration
Realistic simulation of an environment, chat rooms,
radiotransmissions
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TABLE 6. CLIENT FACTORSThose factors that reside within the
client and that may affect performance in areas of occupation.
Client factors include body functions and body structures.Knowledge
about body functions and structures is considered when determining
which functions and structures are needed to carry out an
occupation/activity andhow the body functions and structures may be
changed as a result of engaging in an occupation/activity. Body
functions are the physiological functions of bodysystems (including
psychological functions) (WHO, 2001, p. 10). Body structures are
anatomical parts of the body such as organs, limbs and their
components[that support body function] (WHO, 2001, p. 10).
Client Factor
n BODY FUNCTION CATEGORIESa
Mental functions (affective, cognitive, perceptual) Global
mental functions
Specific mental functions
624 November/December 2002, Volume 56, Number 6
TABLE 5. ACTIVITY DEMANDSThe aspects of an activity, which
include the objects, space, social demands, sequencing or timing,
required actions, and required underlying body functions andbody
structure needed to carry out the activity.
Activity Demand Aspects
Objects and their properties
Space demands (relates to physical context)
Social demands (relates to social and cultural contexts)
Sequence and timing
Required actions
Required body functions
Required body structures
Examples
Tools (scissors, dishes, shoes, volleyball)
Materials (paints, milk, lipstick)
Equipment (workbench, stove, basketball hoop)
Inherent properties (heavy, rough, sharp, colorful, loud,
bittertasting)
Large open space outdoors required for a baseball game
Rules of game
Expectations of other participants in activity (e.g., sharing
ofsupplies)
Stepsto make tea: gather cup and tea bag, heat water, pourwater
into cup, etc.
Sequenceheat water before placing tea bag in water
Timingleave tea bag to steep for 2 minutes
Gripping handlebar
Choosing a dress from closet
Answering a question
Mobility of joints
Level of consciousness
Number of hands
Number of eyes
Definition
The tools, materials, and equipment used in the process of
carrying outthe activity
The physical environmental requirements of the activity (e.g.,
size, ar-rangement, surface, lighting, temperature, noise,
humidity, ventilation)
The social structure and demands that may be required by the
activity
The process used to carry out the activity (specific steps,
sequence, timing requirements)
The usual skills that would be required by any performer to
carry out theactivity. Motor, process, and communication
interaction skills shouldeach be considered. The performance skills
demanded by an activitywill be correlated with the demands of the
other activity aspects (i.e.,objects, space)
The physiological functions of body systems (including
psychologicalfunctions) (WHO, 2001, p. 10) that are required to
support the actionsused to perform the activity.
Anatomical parts of the body such as organs, limbs, and their
compo-nents [that support body function] (WHO, 2001, p. 10) that
arerequired to perform the activity.
Selected Classifications From ICF and Occupational Therapy
Examples
Consciousness functionslevel of arousal, level of
consciousness.
Orientation functionsto person, place, time, self, and
others.
Sleepamount and quality of sleep. Note: Sleep and sleep patterns
are assessed in relation to how they affect ability to effec-tively
engage in occupations and in daily life activities.
Temperament and personality functionsconscientiousness,
emotional stability, openness to experience. Note: These func-tions
are assessed relative to their influence on the ability to engage
in occupations and in daily life activities.
Energy and drive functionsmotivation, impulse control,
interests, values.
Attention functionssustained attention, divided attention.
Memory functionsretrospective memory, prospective memory.
Perceptual functionsvisuospatial perception, interpretation of
sensory stimuli (tactile, visual, auditory, olfactory,
gustatory).
Thought functionsrecognition, categorization, generalization,
awareness of reality, logical/coherent thought, appropriatethought
content.
(Continued)
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The American Journal of Occupational Therapy 625
Sensory functions and pain
Seeing and related functions
Hearing and vestibular functions
Additional sensory functions
Pain
Neuromusculoskeletal and movement-related functions
Functions of joints and bones
Muscle functions
Movement functions
Cardiovascular, hematological, immunological, and respiratory
system function
Cardiovascular system function
Hematological and immunological system function
Higher-level cognitive functionsjudgment, concept formation,
time management, problem solving, decision-making.
Mental functions of languageable to receive language and express
self through spoken and written or sign language. Note:This
function is assessed relative to its influence on the ability to
engage in occupations and in daily life activities.
Calculation functionsable to add or subtract. Note: These
functions are assessed relative to their influence on the ability
toengage in occupations and in daily life activities (e.g., making
change when shopping).
Mental functions of sequencing complex movementmotor
planning.
Psychomotor functionsappropriate range and regulation of motor
response to psychological events.
Emotional functionsappropriate range and regulation of emotions,
self-control.
Experience of self and time functionsbody image, self-concept,
self-esteem.
Seeing functionsvisual acuity, visual field functions.
Hearing functionresponse to sound. Note: This function is
assessed in terms of its presence or absence and its affect
onengaging in occupations and in daily life activities.
Vestibular functionbalance.
Taste functionability to discriminate tastes.
Smell functionability to discriminate smell.
Proprioceptive functionkinesthesia, joint position sense.
Touch functionssensitivity to touch, ability to
discriminate.
Sensory functions related to temperature and other
stimulisensitivity to temperature, sensitivity to pressure, ability
to dis-criminate temperature and pressure.
Sensations of paindull pain, stabbing pain.
Mobility of joint functionspassive range of motion.
Stability of joint functionspostural alignment. Note: This
refers to physiological stability of the joint related to its
structuralintegrity as compared to the motor skill of aligning the
body while moving in relation to task objects.
Mobility of bone functionsfrozen scapula, movement of carpal
bones.
Muscle power functionsstrength.
Muscle tone functionsdegree of muscle tone (e.g., flaccidity,
spasticity).
Muscle endurance functionsendurance.
Motor reflex functionsstretch reflex, asymmetrical tonic neck
reflex.
Involuntary movement reaction functionsrighting reactions,
supporting reactions.
Control of voluntary movement functionseyehand coordination,
bilateral integration, eyefoot coordination.
Involuntary movement functionstremors, tics, motor
perseveration.
Gait pattern functionswalking patterns and impairments, such as
asymmetric gait, stiff gait. (Note: Gait patterns areassessed in
relation to how they affect ability to engage in occupations and in
daily life activities.)
Blood pressure functionshypertension, hypotension, postural
hypotension.
Occupational therapists and occupational therapy assistants have
knowledge of these body functions and understand broadlythe
interaction that occurs between these functions and engagement in
occupation to support participation. Some therapistsmay specialize
in evaluating and intervening with a specific function as it is
related to supporting performance and engage-ment in occupations
and activities targeted for intervention.
(Continued)
TABLE 6. CLIENT FACTORS(Continued)
Client Factor Selected Classifications From ICF and Occupational
Therapy Examples
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Respiratory system function
Additional functions and sensations of the cardiovascular and
respiratory systems
Voice and speech functions
Digestive, metabolic, and endocrine system function
Digestive system function
Metabolic system and endocrine system function
Genitourinary and reproductive functions
Urinary functions
Genital and reproductive functions
Skin and related structure functions
Skin functions
Hair and nail functions
n BODY STRUCTURE CATEGORIESb
Structure of the nervous system
The eye, ear, and related structures
Structures involved in voice and speech
Structures of the cardiovascular,immunological, and respiratory
systems
Structures related to the digestive
Structure related to the genitourinary and reproductive
systems
Structures related to movement
Skin and related structures
Respiration functionsrate, rhythm, and depth.
Exercise tolerance functionsphysical endurance, aerobic
capacity, stamina, and fatigability.
Occupational therapists and occupational therapy assistants have
knowledge of these body functions and understand broadlythe
interaction that occurs between these functions and engagement in
occupation to support participation. Some therapistsmay specialize
in evaluating and intervening with a specific function as it is
related to supporting performance and engage-ment in occupations
and activities targeted for intervention.
Protective functions of the skinpresence or absence of wounds,
cuts, or abrasions.
Repair function of the skinwound healing.
Occupational therapists and occupational therapy assistants have
knowledge of these body functions and understand broadlythe
interaction that occurs between these functions and engagement in
occupation to support participation. Some therapistsmay specialize
in evaluating and intervening with a specific function as it is
related to supporting performance and engage-ment in occupations
and activities targeted for intervention.
Occupational therapists and occupational therapy assistants have
knowledge of these body functions and understand broadlythe
interaction that occurs between these structures and engagement in
occupation to support participation. Some thera-pists may
specialize in evaluating and intervening with a specific structures
as it is related to supporting performance andengagement in
occupations and activities targeted for intervention.
626 November/December 2002, Volume 56, Number 6
TABLE 6. CLIENT FACTORS(Continued)
Client Factor Selected Classifications From ICF and Occupational
Therapy Examples
Note. The reader is strongly encouraged to use International
Classification of Functioning, Disability and Health (ICF) in
collaboration with this table to provide for in-depth
informationwith respect to classification in terms (inclusion and
exclusion).aCategories and classifications are adapted from the ICF
(WHO, 2001). bCategories are from the ICF (WHO, 2001).
Client Factor Classifications (Classification are not delineated
in the Body Structure section of this table)
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The American Journal of Occupational Therapy 627
TABLE 7. OCCUPATIONAL THERAPY INTERVENTION APPROACHESSpecific
strategies selected to direct the process of intervention that are
based on the clients desired outcome, evaluation data, and
evidence.
Approach
Create, promote (health promotion)aan inter-vention approach
that does not assume a disabilityis present or that any factors
would interfere withperformance. This approach is designed to
provideenriched contextual and activity experiences that
willenhance performance for all persons in the naturalcontexts of
life (adapted from Dunn, McClain,Brown, & Youngstrom, 1998, p.
534).
Establish, restore (remediation, restoration)aan intervention
approach designed to change clientvariables to establish a skill or
ability that has notyet developed or to restore a skill or ability
that hasbeen impaired (adapted from Dunn et al., 1998, p. 533).
Maintainan intervention approach designed toprovide the supports
that will allow clients to pre-serve their performance capabilities
that they haveregained, that continue to meet their
occupationalneeds, or both. The assumption is that without
con-tinued maintenance intervention, performance woulddecrease,
occupational needs would not be met, orboth, thereby affecting
health and quality of lif