Occupational Therapy Practice Framework: Domain and Process Fourth Edition

GUIDELINES
Occupational Therapy Practice

Framework: Domain and Process
Fourth Edition
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Contents Preface
Preface .....................................................................1 The fourth edition of the Occupational Therapy Practice Framework: Domain
Definitions ..........................................................1
and Process (hereinafter referred to as the OTPF–4), is an official document of
Evolution of This Document ..............................2
Vision for This Work ..........................................4 the American Occupational Therapy Association (AOTA). Intended for
Introduction ..............................................................4 occupational therapy practitioners and students, other health care
Occupation and Occupational Science ...........4
OTPF Organization .......................................4 professionals, educators, researchers, payers, policymakers, and consumers,
Cornerstones of Occupational Therapy the OTPF–4 presents a summary of interrelated constructs that describe
Practice ......................................................6
Domain .....................................................................6 occupational therapy practice.
Occupations .......................................................7
Contexts ............................................................9
Performance Patterns .....................................12 Definitions
Performance Skills ..........................................13
Within the OTPF–4, occupational therapy is defined as the therapeutic use of
Client Factors ..................................................15
Process ..................................................................17 everyday life occupations with persons, groups, or populations (i.e., the client)
Overview of the Occupational Therapy for the purpose of enhancing or enabling participation. Occupational therapy
Process ....................................................17
Evaluation ........................................................21 practitioners use their knowledge of the transactional relationship among the
Intervention ......................................................24 client, the client’s engagement in valuable occupations, and the context to
Outcomes ........................................................26
Conclusion .............................................................28 design occupation-based intervention plans. Occupational therapy services
Tables ....................................................................29 are provided for habilitation, rehabilitation, and promotion of health and
References .............................................................68
Table 1. Examples of Clients: Persons, Groups,
wellness for clients with disability- and non–disability-related needs. These
and Populations ............................................ 29 services include acquisition and preservation of occupational identity for
Table 2. Occupations ......................................30
Table 3. Examples of Occupations for Persons,
clients who have or are at risk for developing an illness, injury, disease,
Groups, and Populations ..............................35 disorder, condition, impairment, disability, activity limitation, or participation
Table 4. Context: Environmental Factors .......36
restriction (AOTA, 2011; see the glossary in Appendix A for additional
Table 5. Context: Personal Factors ................40
Table 6. Performance Patterns .......................41 definitions).
Table 7. Performance Skills for Persons .......43
When the term occupational therapy practitioners is used in this
Table 8. Performance Skills for Groups .........50
Table 9. Client Factors ....................................51 document, it refers to both occupational therapists and occupational therapy
Table 10. Occupational Therapy Process for
assistants (AOTA, 2015b). Occupational therapists are responsible for all
Persons, Groups, and Populations .............55
Table 11. Occupation and Activity aspects of occupational therapy service delivery and are accountable for the
Demands ......................................................57 safety and effectiveness of the occupational therapy service delivery process.
AOTA OFFICIAL DOCUMENT 1
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p1
GUIDELINES
Table 12. Types of Occupational Therapy Occupational therapy assistants deliver occupational therapy services under
Interventions ................................................59
Table 13. Approaches to Intervention ............63 the supervision of and in partnership with an occupational therapist (AOTA,
Table 14. Outcomes ........................................65 2020a).
Exhibit 1. Aspects of the Occupational Therapy
Domain ...........................................................7 The clients of occupational therapy are typically classified as persons
Exhibit 2. Operationalizing the Occupational (including those involved in care of a client), groups (collections of individuals
Therapy Process .........................................16
Figure 1. Occupational Therapy Domain and
having shared characteristics or a common or shared purpose; e.g., family
Process ..........................................................5 members, workers, students, people with similar interests or occupational
Authors ............................................................72
Acknowledgments ...........................................73
challenges), and populations (aggregates of people with common attributes

Appendix A. Glossary .....................................74 such as contexts, characteristics, or concerns, including health risks; Scaffa
Index ................................................................85
& Reitz, 2014). People may also consider themselves as part of a community,
such as the Deaf community or the disability community; a community is a
collection of populations that is changeable and diverse and includes various
people, groups, networks, and organizations (Scaffa, 2019; World Federation
of Occupational Therapists [WFOT], 2019). It is important to consider the
community or communities with which a client identifies throughout the
occupational therapy process.
Whether the client is a person, group, or population, information about the
client’s wants, needs, strengths, contexts, limitations, and occupational risks is
gathered, synthesized, and framed from an occupational perspective. Throughout
the OTPF–4, the term client is used broadly to refer to persons, groups, and
Copyright © 2020 by the American
Occupational Therapy Association. populations unless otherwise specified. In the OTPF–4, “group” as a client is distinct
Citation: American Occupational Therapy from “group” as an intervention approach. For examples of clients, see Table 1 (all
Association. (2020). Occupational therapy tables are placed together at the end of this document). The glossary in Appendix
practice framework: Domain and process
(4th ed.). American Journal of Occupational A provides definitions of other terms used in this document.
Therapy, 74(Suppl. 2), 7412410010. https://doi.
org/10.5014/ajot.2020.74S2001
Evolution of This Document
ISBN: 978-1-56900-488-3
The Occupational Therapy Practice Framework was originally developed to
For permissions inquiries, visit https://www.
copyright.com.
articulate occupational therapy’s distinct perspective and contribution to
promoting the health and participation of persons, groups, and populations
through engagement in occupation. The first edition of the OTPF emerged
from an examination of documents related to the Occupational Therapy Product
Output Reporting System and Uniform Terminology for Reporting Occupational
Therapy Services (AOTA, 1979). Originally a document that responded to a federal
requirement to develop a uniform reporting system, this text gradually shifted to
describing and outlining the domains of concern of occupational therapy.
The second edition of Uniform Terminology for Occupational Therapy
(AOTA, 1989) was adopted by the AOTA Representative Assembly (RA) and
published in 1989. The document focused on delineating and defining only
the occupational performance areas and occupational performance components
that are addressed in occupational therapy direct services. The third and final
edition of Uniform Terminology for Occupational Therapy (UT–III; AOTA, 1994)
was adopted by the RA in 1994 and was “expanded to reflect current practice
and to incorporate contextual aspects of performance” (p. 1047). Each revision
2 AOTA OFFICIAL DOCUMENT
GUIDELINES
reflected changes in practice and provided consistent n The terms occupation and activity are more clearly
terminology for use by the profession. defined.
In fall 1998, the AOTA Commission on Practice (COP) n For occupations, the definition of sexual activity as an
embarked on the journey that culminated in the activity of daily living is revised, health management is
Occupational Therapy Practice Framework: Domain added as a general occupation category, and intimate
and Process (AOTA, 2002a). At that time, AOTA also partner is added in the social participation category
published The Guide to Occupational Therapy Practice (see Table 2).
(Moyers, 1999), which outlined contemporary practice n The contexts and environments aspect of the

for the profession. Using this document and the feedback occupational therapy domain is changed to context on
received during the review process for the UT–III, the COP the basis of the World Health Organization (WHO; 2008)
proceeded to develop a document that more fully taxonomy from the International Classification of
articulated occupational therapy. Functioning, Disability and Health (ICF) in an effort
The OTPF is an ever-evolving document. As an to adopt standard, well-accepted definitions (see
official AOTA document, it is reviewed on a 5-year Table 4).
cycle for usefulness and the potential need for further n For the client factors category of body functions,
refinements or changes. During the review period, the COP gender identity is now included under “experience of
collects feedback from AOTA members, scholars, authors, self and time,” the definition of psychosocial is
practitioners, AOTA volunteer leadership and staff, and expanded to match the ICF description, and
other stakeholders. The revision process ensures that the interoception is added under sensory functions.
OTPF maintains its integrity while responding to internal and n For types of intervention, “preparatory methods and
external influences that should be reflected in emerging tasks” has been changed to “interventions to support
concepts and advances in occupational therapy. occupations” (see Table 12).
The OTPF was first revised and approved by the RA in n For outcomes, transitions and discontinuation are
2008. Changes to the document included refinement of the discussed as conclusions to occupational therapy
writing and the addition of emerging concepts and changes services, and patient-reported outcomes are
in occupational therapy. The rationale for specific changes addressed (see Table 14).
can be found in Table 11 of the OTPF–2 (AOTA, 2008, n Five new tables are added to expand on and clarify
pp. 665–667). concepts:
In 2012, the process of review and revision of the + Table 1. Examples of Clients: Persons, Groups,
OTPF was initiated again, and several changes were and Populations
made. The rationale for specific changes can be found
+ Table 3. Examples of Occupations for Persons,
Groups, and Populations
on page S2 of the OTPF–3 (AOTA, 2014).
+ Table 7. Performance Skills for Persons (includes
In 2018, the process to revise the OTPF began again.
examples of effective and ineffective
After member review and feedback, several modifications
performance skills)
were made and are reflected in this document:
+ Table 8. Performance Skills for Groups
n The focus on group and population clients is (includes examples of the impact of ineffective
increased, and examples are provided for both. individual performance skills on group
n Cornerstones of occupational therapy practice are collective outcome)
identified and described as foundational to the + Table 10. Occupational Therapy Process for
success of occupational therapy practitioners. Persons, Groups, and Populations.
n Occupational science is more explicitly described n Throughout, the use of OTPF rather than Framework
and defined. acknowledges the current requirements for a unique
GUIDELINES
identifier to maximize digital discoverability and to students, communication with the public and
promote brevity in social media communications. It policymakers, and provision of language that can shape
also reflects the longstanding use of the acronym in and be shaped by research.
academic teaching and clinical practice.
n Figure 1 has been revised to provide a simplified Occupation and Occupational Science
visual depiction of the domain and process of Embedded in this document is the occupational therapy
occupational therapy. profession’s core belief in the positive relationship
between occupation and health and its view of people as

Vision for This Work occupational beings. Occupational therapy practice
Although this edition of the OTPF represents the latest in emphasizes the occupational nature of humans and the
the profession’s efforts to clearly articulate the importance of occupational identity (Unruh, 2004) to
occupational therapy domain and process, it builds on a healthful, productive, and satisfying living. As Hooper and
set of values that the profession has held since its Wood (2019) stated,
founding in 1917. The original vision had at its center a
profound belief in the value of therapeutic occupations as A core philosophical assumption of the profession, therefore, is that by
virtue of our biological endowment, people of all ages and abilities
a way to remediate illness and maintain health (Slagle, require occupation to grow and thrive; in pursuing occupation, humans
1924). The founders emphasized the importance of express the totality of their being, a mind–body–spirit union. Because
human existence could not otherwise be, humankind is, in essence,
establishing a therapeutic relationship with each client occupational by nature. (p. 46)
and designing a treatment plan based on knowledge
Occupational science is important to the practice of
about the client’s environment, values, goals, and desires
occupational therapy and “provides a way of thinking that
(Meyer, 1922). They advocated for scientific practice
enables an understanding of occupation, the occupational
based on systematic observation and treatment (Dunton,
nature of humans, the relationship between occupation,
1934). Paraphrased using today’s lexicon, the founders
health and well-being, and the influences that shape
proposed a vision that was occupation based, client
occupation” (WFOT, 2012b, p. 2). Many of its concepts are
centered, contextual, and evidence based—the vision
emphasized throughout the OTPF–4, including
articulated in the OTPF–4.
occupational justice and injustice, identity, time use,
satisfaction, engagement, and performance.
Introduction
OTPF Organization
The purpose of a framework is to provide a structure or The OTPF–4 is divided into two major sections: (1) the
base on which to build a system or a concept domain, which outlines the profession’s purview and the
(“Framework,” 2020). The OTPF describes the central areas in which its members have an established body
concepts that ground occupational therapy practice and of knowledge and expertise, and (2) the process,
builds a common understanding of the basic tenets and which describes the actions practitioners take when
vision of the profession. The OTPF–4 does not serve as a providing services that are client centered and
taxonomy, theory, or model of occupational therapy. By focused on engagement in occupations. The
design, the OTPF–4 must be used to guide occupational profession’s understanding of the domain and process
therapy practice in conjunction with the knowledge and of occupational therapy guides practitioners as they
evidence relevant to occupation and occupational seek to support clients’ participation in daily living,
therapy within the identified areas of practice and with the which results from the dynamic intersection of clients,
appropriate clients. In addition, the OTPF–4 is intended their desired engagements, and their contexts
to be a valuable tool in the academic preparation of (including environmental and personal factors;
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Figure 1. Occupational Therapy Domain and Process
D OM A I N
Oc c up at ions
C
rs

Intervention
on
to
tex
c
Fa
ts
on
Client
Ou
Evaluati
Achieving health,
tcomes
well-being, and
participation in life
s
through engagement
t t ern
in occupation.
Pe r f
Pa
PR
or
OCESS
ce
an
m
a n
ce m
Ski o r
lls Pe r f
Christiansen & Baum, 1997; Christiansen et al., 2005; n Well-being—“a general term encompassing the total
Law et al., 2005). universe of human life domains, including physical,
“Achieving health, well-being, and participation in life mental, and social aspects, that make up what can be
through engagement in occupation” is the overarching called a ‘good life’” (WHO, 2006, p. 211).
statement that describes the domain and process of n Participation—“involvement in a life situation” (WHO,
occupational therapy in its fullest sense. This statement 2008, p. 10). Participation occurs naturally when clients
acknowledges the profession’s belief that active are actively involved in carrying out occupations or daily
engagement in occupation promotes, facilitates, life activities they find purposeful and meaningful. More
supports, and maintains health and participation. These specific outcomes of occupational therapy intervention
interrelated concepts include
are multidimensional and support the end result of
n Health—“a state of complete physical, mental, participation.
and social well-being, and not merely the n Engagement in occupation—performance of
absence of disease or infirmity” (WHO, 2006, occupations as the result of choice, motivation, and
p. 1). meaning within a supportive context (including
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environmental and personal factors). Engagement Occupational therapy cornerstones provide a

includes objective and subjective aspects of clients’ fundamental foundation for practitioners from which to
experiences and involves the transactional interaction view clients and their occupations and facilitate the
of the mind, body, and spirit. Occupational therapy occupational therapy process. Practitioners develop the
intervention focuses on creating or facilitating cornerstones over time through education, mentorship,
opportunities to engage in occupations that lead to and experience. In addition, the cornerstones are ever
participation in desired life situations (AOTA, 2008). evolving, reflecting developments in occupational therapy
practice and occupational science.
Although the domain and process are described

Many contributors influence each cornerstone. Like
separately, in actuality they are linked inextricably in a
the cornerstones, the contributors are complementary
transactional relationship. The aspects that constitute
and interact to provide a foundation for practitioners.
the domain and those that constitute the process exist in
The contributors include, but are not limited to, the
constant interaction with one another during the delivery of
following:
occupational therapy services. Figure 1 represents
aspects of the domain and process and the overarching n Client-centered practice
goal of the profession as achieving health, well-being, and n Clinical and professional reasoning
participation in life through engagement in occupation. n Competencies for practice
Although the figure illustrates these two elements in n Cultural humility
distinct spaces, in reality the domain and process interact n Ethics
in complex and dynamic ways as described throughout n Evidence-informed practice
this document. The nature of the interactions is n Inter- and intraprofessional collaborations
impossible to capture in a static one-dimensional image. n Leadership
n Lifelong learning
Cornerstones of Occupational Therapy Practice n Micro and macro systems knowledge
The transactional relationship between the domain and n Occupation-based practice
process is facilitated by the occupational therapy n Professionalism
practitioner. Occupational therapy practitioners have n Professional advocacy
distinct knowledge, skills, and qualities that contribute to the n Self-advocacy
success of the occupational therapy process, described in n Self-reflection
this document as “cornerstones.” A cornerstone can be n Theory-based practice.
defined as something of great importance on which
everything else depends (“Cornerstone,” n.d.), and the Domain
following cornerstones of occupational therapy help
distinguish it from other professions: Exhibit 1 identifies the aspects of the occupational
therapy domain: occupations, contexts, performance
n Core values and beliefs rooted in occupation (Cohn,
patterns, performance skills, and client factors. All
2019; Hinojosa et al., 2017)
aspects of the domain have a dynamic interrelatedness.
n Knowledge of and expertise in the therapeutic use of
All aspects are of equal value and together interact to
occupation (Gillen, 2013; Gillen et al., 2019)
affect occupational identity, health, well-being, and
n Professional behaviors and dispositions (AOTA
participation in life.
2015a, 2015c)
Occupational therapists are skilled in evaluating all
n Therapeutic use of self (AOTA, 2015c; Taylor, 2020).
aspects of the domain, the interrelationships among the
These cornerstones are not hierarchical; instead, each aspects, and the client within context. Occupational
concept influences the others. therapy practitioners recognize the importance and
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Exhibit 1. Aspects of the Occupational Therapy Domain

All aspects of the occupational therapy domain transact to support engagement, participation, and health. This exhibit does not imply
a hierarchy.
Performance Performance
Occupations Contexts Patterns Skills Client Factors
Activities of daily living (ADLs) Environmental Habits Motor skills Values, beliefs,
Instrumental activities of daily factors Routines Process skills and spirituality
living (IADLs) Personal factors Roles Social interaction skills Body functions
Health management Rituals Body structures
Rest and sleep

Education
Work
Play
Leisure
Social participation
impact of the mind–body–spirit connection on to a specific client’s engagement or context (Schell et al.,
engagement and participation in daily life. Knowledge of 2019) and, therefore, can be selected and designed to
the transactional relationship and the significance of enhance occupational engagement by supporting the
meaningful and productive occupations forms the basis for development of performance skills and performance
the use of occupations as both the means and the ends patterns. Both occupations and activities are used as
of interventions (Trombly, 1995). This knowledge sets interventions by practitioners. For example, a practitioner
occupational therapy apart as a distinct and valuable may use the activity of chopping vegetables during an
service (Hildenbrand & Lamb, 2013) for which a focus on intervention to address fine motor skills with the ultimate
the whole is considered stronger than a focus on isolated
goal of improving motor skills for the occupation of
aspects of human functioning.
preparing a favorite meal. Participation in occupations is
The discussion that follows provides a brief
considered both the means and the end in the
explanation of each aspect of the domain. Tables included
occupational therapy process.
at the end of the document provide additional
Occupations occur in contexts and are influenced by
descriptions and definitions of terms.
the interplay among performance patterns, performance
skills, and client factors. Occupations occur over time;
Occupations
have purpose, meaning, and perceived utility to the client;
Occupations are central to a client’s (person’s, group’s, or
and can be observed by others (e.g., preparing a meal) or
population’s) health, identity, and sense of competence
be known only to the person involved (e.g., learning
and have particular meaning and value to that client. “In
through reading a textbook). Occupations can involve the
occupational therapy, occupations refer to the everyday
activities that people do as individuals, in families, and with execution of multiple activities for completion and can
communities to occupy time and bring meaning and result in various outcomes.
purpose to life. Occupations include things people The OTPF–4 identifies a broad range of occupations
need to, want to and are expected to do” (WFOT, 2012a, categorized as activities of daily living (ADLs), instrumental
para. 2). activities of daily living (IADLs), health management, rest
In the OTPF–4, the term occupation denotes and sleep, education, work, play, leisure, and social
personalized and meaningful engagement in daily life participation (Table 2). Within each of these nine broad
events by a specific client. Conversely, the term activity categories of occupation are many specific occupations. For
denotes a form of action that is objective and not related example, the broad category of IADLs has specific
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occupations that include grocery shopping and money Because occupational performance does not exist in a
management. vacuum, context must always be considered. For example,
When occupational therapy practitioners work with for a client who lives in food desert, lack of access to a
clients, they identify the types of occupations clients grocery store may limit their ability to have balance in their
engage in individually or with others. Differences among performance of IADLs such as cooking and grocery
clients and the occupations they engage in are complex shopping or to follow medical advice from health care
and multidimensional. The client’s perspective on how an professionals on health management and preparation of
occupation is categorized varies depending on that nutritious meals. For this client, the limitation is not caused by

client’s needs, interests, and contexts. Moreover, values impaired client factors or performance skills but rather is
attached to occupations are dependent on cultural and shaped by the context in which the client functions. This
sociopolitical determinants (Wilcock & Townsend, 2019). context may include policies that resulted in the decline of
For example, one person may perceive gardening as commercial properties in the area, a socioeconomic status
leisure, whereas another person, who relies on the food that does not enable the client to live in an area with access
produced from that garden to feed their family or to a grocery store, and a social environment in which lack of
community, may perceive it as work. Additional examples access to fresh food is weighed as less important than the
of occupations for persons, groups, and populations can social supports the community provides.
be found in Table 3. Occupational therapy practitioners recognize that
The ways in which clients prioritize engagement in health is supported and maintained when clients are able
selected occupations may vary at different times. For to engage in home, school, workplace, and community
example, clients in a community psychiatric rehabilitation life. Thus, practitioners are concerned not only with
setting may prioritize registering to vote during an election occupations but also with the variety of factors that disrupt
season and food preparation during holidays. The unique or empower those occupations and influence clients’
features of occupations are noted and analyzed by engagement and participation in positive health-
occupational therapy practitioners, who consider all promoting occupations (Wilcock & Townsend, 2019).
components of the engagement and use them effectively Although engagement in occupations is generally
as both a therapeutic tool and a way to achieve the considered a positive outcome of the occupational therapy
targeted outcomes of intervention. process, it is important to consider that a client’s history
The extent to which a client is engaged in a particular might include negative, traumatic, or unhealthy
occupation is also important. Occupational therapy occupational participation (Robinson Johnson & Dickie,
practitioners assess the client’s ability to engage in 2019). For example, a person who has experienced a
occupational performance, defined as the traumatic sexual encounter might negatively perceive and
accomplishment of the selected occupation resulting from react to engagement in sexual intimacy. A person with an
the dynamic transaction among the client, their contexts, eating disorder might engage in eating in a maladaptive
and the occupation. Occupations can contribute to a well- way, deterring health management and physical health.
balanced and fully functional lifestyle or to a lifestyle that is In addition, some occupations that are meaningful to a
out of balance and characterized by occupational client might also hinder performance in other occupations
dysfunction. For example, excessive work without or negatively affect health. For example, a person who
sufficient regard for other aspects of life, such as sleep or spends a disproportionate amount of time playing video
relationships, places clients at risk for health problems. games may develop a repetitive stress injury and may
External factors, including war, natural disasters, or have less balance in their time spent on IADLs and other
extreme poverty, may hinder a client’s ability to create forms of social participation. A client engaging in the
balance or engage in certain occupations (AOTA, 2017b; recreational use of prescription pain medications may
McElroy et al., 2012). experience barriers to participation in previously
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important occupations such as work or spending time with of assistance required, if clients are satisfied with their
family. performance. In contrast to definitions of independence
Occupations have the capacity to support or promote that imply direct physical interaction with the environment
other occupations. For example, children engage in play or objects within the environment, occupational therapy
to develop the performance skills that later facilitate practitioners consider clients to be independent whether
engagement in leisure and work. Adults may engage in they perform the specific occupations by themselves, in an
social participation and leisure with an intimate partner adapted or modified environment, with the use of various
that may improve satisfaction with sexual activity. The devices or alternative strategies, or while overseeing

goal of engagement in sleep and health management activity completion by others (AOTA, 2002b). For
includes maintaining or improving performance of work, example, a person with spinal cord injury who directs a
leisure, social participation, and other occupations. personal care assistant to assist them with ADLs is
Occupations are often shared and done with others. demonstrating independence in this essential aspect of
Those that implicitly involve two or more individuals are their life.
termed co-occupations (Zemke & Clark, 1996). Co- It is also important to acknowledge that not all clients
occupations are the most interactive of all social view success as independence. Interdependence, or
occupations. Central to the concept of co-occupation is that co-occupational performance, can also be an indicator
two or more individuals share a high level of physicality, of personal success. How a client views success may
emotionality, and intentionality (Pickens & Pizur-Barnekow, be influenced by their client factors, including their
2009). In addition, co-occupations can be parallel (different culture.
occupations in close proximity to others; e.g., reading while
others listen to music when relaxing at home) and shared Contexts
(same occupation but different activities; e.g., preparing Context is a broad construct defined as the environmental
different dishes for a meal; Zemke & Clark, 1996). and personal factors specific to each client (person, group,
Caregiving is a co-occupation that requires active population) that influence engagement and participation
participation by both the caregiver and the recipient of in occupations. Context affects clients’ access to
care. For the co-occupations required during parenting, occupations and the quality of and satisfaction with
the socially interactive routines of eating, feeding, and performance (WHO, 2008). Practitioners recognize that
comforting may involve the parent, a partner, the child, for people to truly achieve full participation, meaning, and
and significant others (Olson, 2004). The specific purpose, they must not only function but also engage
occupations inherent in this social interaction are comfortably within their own distinct combination of
reciprocal, interactive, and nested (Dunlea, 1996; Esdaile contexts.
& Olson, 2004). Consideration of co-occupations by In the literature, the terms environment and context
practitioners supports an integrated view of the client’s often are used interchangeably, but this may result in
engagement in the context of relationship to significant confusion when describing aspects of situations in which
others. occupational engagement takes place. Understanding the
Occupational participation can be considered contexts in which occupations can and do occur provides
independent whether it occurs individually or with others. It practitioners with insights into the overarching, underlying,
is important to acknowledge that clients can be and embedded influences of environmental factors and
independent in living regardless of the amount of personal factors on engagement in occupations.
assistance they receive while completing occupations.
Clients may be considered independent even when they Environmental Factors
direct others (e.g., caregivers) in performing the actions Environmental factors are aspects of the physical, social,
necessary to participate, regardless of the amount or kind and attitudinal surroundings in which people live and
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conduct their lives (Table 4). Environmental factors n For groups, absence of healthy social opportunities
influence functioning and disability and have positive for those abstaining from alcohol use
aspects (facilitators) or negative aspects (barriers or n For populations, businesses that are not welcoming
hindrances; WHO, 2008). Environmental factors include to people who identify as LGBTQ+. (Note: In this
n Natural environment and human-made changes to document, LGBTQ+ is used to represent the large
the environment: Animate and inanimate elements of and diverse communities and individuals with
the natural or physical environment and nonmajority sexual orientations and gender
components of that environment that have been identities.)

modified by people, as well as characteristics of
human populations within that environment. Addressing these barriers, such as by widening a doorway
Engagement in human occupation influences the to allow access, results in environmental supports that
sustainability of the natural environment, and enable participation. A client who has difficulty performing
changes to human behavior can have a positive effectively in one context may be successful when the
impact on the environment (Dennis et al., 2015). natural environment has human-made modifications or if the
n Products and technology: Natural or human-made client uses applicable products and technology. In addition,
products or systems of products, equipment, and occupational therapy practitioners must be aware of norms
related to, for example, eating or deference to medical
technology that are gathered, created, produced, or
professionals when working with someone from a culture or
manufactured.
socioeconomic status that differs from their own.
n Support and relationships: People or animals that
provide practical physical or emotional support, Personal Factors
nurturing, protection, assistance, and connections to Personal factors are the unique features of a person that
other persons in the home, workplace, or school or at are not part of a health condition or health state and that
play or in other aspects of daily occupations. constitute the particular background of the person’s life
n Attitudes: Observable evidence of customs, and living (Table 5). Personal factors are internal
practices, ideologies, values, norms, factual beliefs, influences affecting functioning and disability and are not
considered positive or negative but rather reflect the
and religious beliefs held by people other than the
essence of the person—“who they are.” When clients
client.
provide demographic information, they are typically
n Services, systems, and policies: Benefits,
describing personal factors. Personal factors also
structured programs, and regulations for operations
include customs, beliefs, activity patterns, behavioral
provided by institutions in various sectors of society
standards, and expectations accepted by the society or
designed to meet the needs of persons, groups, and
cultural group of which a person is a member.
populations.
Personal factors are generally considered to be
When people interact with the world around them, enduring, stable attributes of the person, although some
environmental factors can either enable or restrict personal factors change over time. They include, but are
not limited to, the following:
participation in meaningful occupations and can present
barriers to or supports and resources for service delivery.
n Chronological age
n Sexual orientation (sexual preference, sexual
Examples of environmental barriers that restrict
identity)
participation include the following: n Gender identity
n For persons, doorway widths that do not allow for n Race and ethnicity
wheelchair passage n Cultural identification and attitudes
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n Social background, social status, and socioeconomic occupations and occupational justice complements
status WHO’s (2008) perspective on health. To broaden the
n Upbringing and life experiences understanding of the effects of disease and disability on
n Habits and past and current behavioral patterns
health, WHO emphasized that health can be affected by the
n Psychological assets, temperament, unique
inability to carry out occupations and activities and
character traits, and coping styles
participate in life situations caused by contextual barriers
n Education
n Profession and professional identity and by problems that exist in body structures and body

n Lifestyle functions. The OTPF–4 identifies occupational justice as
n Health conditions and fitness status (that may affect both an aspect of contexts and an outcome of intervention.
the person’s occupations but are not the primary Occupational justice involves the concern that
concern of the occupational therapy encounter). occupational therapy practitioners have with respect,
fairness, and impartiality and equitable opportunities
For example, siblings share personal factors of race when considering the contexts of persons, groups, and
and age, yet for those separated at birth, environmental populations (AOTA, 2015a). As part of the occupational
differences may result in divergent personal factors in therapy domain, practitioners consider how these
terms of cultural identification, upbringing, and life aspects can affect the implementation of occupational
experiences, producing different contexts for their therapy and the target outcome of participation.
individual occupational engagement. Whether separated Practitioners recognize that for individuals to truly
or raised together, as siblings move through life, they may achieve full participation, meaning, and purpose, they
develop differences in sexual orientation, life experience, must not only function but also engage comfortably within
habits, education, profession, and lifestyle. their own distinct combination of contexts (both
Groups and populations are often formed or identified environmental factors and personal factors).
on the basis of shared or similar personal factors that make Examples of contexts that can present occupational
possible occupational therapy assessment and justice issues include the following:
intervention. Of course, individual members of a group or n An alternative school placement for children with
population differ in other personal factors. For example, a mental health and behavioral disabilities that
group of fifth graders in a community public school are provides academic support and counseling but
likely to share age and, perhaps, socioeconomic status. limited opportunities for participation in sports,
Yet race, fitness, habits, and coping styles make each music programs, and organized social activities
group member unlike the others. Similarly, a population of n A residential facility for older adults that offers safety
older adults living in an urban low-income housing and medical support but provides little opportunity for
community may have few personal factors in common other engagement in the role-related occupations that were
than age and current socioeconomic status. once a source of meaning
n A community that lacks accessible and inclusive
Application of Context to Occupational Justice physical environments and provides limited services
Interwoven throughout the concept of context is that of and supports, making participation difficult or even
occupational justice, defined as “a justice that dangerous for people who have disabilities (e.g.,
recognizes occupational rights to inclusive participation lack of screening facilities and services resulting in
in everyday occupations for all persons in society, higher rates of breast cancer among community
regardless of age, ability, gender, social class, or other members)
differences” (Nilsson & Townsend, 2010, p. 58). n A community that lacks financial and other necessary
Occupational therapy’s focus on engagement in resources, resulting in an adverse and
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disproportionate impact of natural disasters and Time use is the manner in which a person manages their
severe weather events on vulnerable populations. activity levels; adapts to changes in routines; and organizes
their days, weeks, and years (Edgelow & Krupa, 2011).
Occupational therapy practitioners recognize areas of Habits are specific, automatic adaptive or maladaptive
occupational injustice and work to support policies, behaviors. Habits may be healthy or unhealthy (e.g.,
actions, and laws that allow people to engage in exercising on a daily basis vs. smoking during every
occupations that provide purpose and meaning in their lunch break), efficient or inefficient (e.g., completing
lives. By understanding and addressing the specific homework after school vs. in the few minutes before the

justice issues in contexts such as an individual’s home, a school bus arrives), and supportive or harmful (e.g.,
group’s shared job site, or a population’s community setting an alarm clock before going to bed vs. not doing
center, practitioners promote occupational therapy so; Clark, 2000; Dunn, 2000; Matuska & Barrett, 2019).
outcomes that address empowerment and self- Routines are established sequences of occupations or
advocacy. activities that provide a structure for daily life; they can also
promote or damage health (Fiese, 2007; Koome et al.,
Performance Patterns 2012; Segal, 2004). Shared routines involve two or more
Performance patterns are the acquired habits, routines, people and take place in a similar manner regardless of
roles, and rituals used in the process of engaging the individuals involved (e.g., routines shared by parents
consistently in occupations and can support or hinder to promote the health of their children; routines shared by
occupational performance (Table 6). Performance coworkers to sort the mail; Primeau, 2000). Shared
patterns help establish lifestyles (Uyeshiro Simon & routines can be nested in co-occupations. For example,
Collins, 2017) and occupational balance (e.g., proportion a young child’s occupation of completing oral hygiene
of time spent in productive, restorative, and leisure with the assistance of an adult is a part of the child’s daily
occupations; Eklund et al., 2017; Wagman et al., 2015) routine, and the adult who provides the assistance may
and are shaped, in part, by context (e.g., consistency, also view helping the young child with oral hygiene as a
work hours, social calendars) and cultural norms (Eklund part of the adult’s own daily routine.
et al., 2017; Larson & Zemke, 2003). Roles have historically been defined as sets of
Time provides an organizational structure or rhythm for behaviors expected by society and shaped by culture and
performance patterns (Larson & Zemke, 2003); for context; they may be further conceptualized and defined
example, an adult goes to work every morning, a child by a person, group, or population (Kielhofner, 2008;
completes homework every day after school, or an Taylor, 2017). Roles are an aspect of occupational
organization hosts a fundraiser every spring. The manner identity—that is, they help define who a person, group, or
in which people think about and use time is influenced by population believes themselves to be on the basis of their
biological rhythms (e.g., sleep–wake cycles), family of occupational history and desires for the future. Certain
origin (e.g., amount of time a person is socialized to roles are often associated with specific activities and
believe should be spent in productive occupations), work occupations; for example, the role of parent is associated
and social schedules (e.g., religious services held on the with feeding children (Kielhofner, 2008; Taylor, 2017).
same day each week), and cyclic cultural patterns (e.g., When exploring roles, occupational therapy practitioners
birthday celebration with cake every year, annual cultural consider the complexity of identity and the limitations
festival; Larson & Zemke, 2003). Other temporal factors associated with assigning stereotypical occupations to
influencing performance patterns are time management and specific roles (e.g., on the basis of gender). Practitioners
time use. Time management is the manner in which a also consider how clients construct their occupations and
person, group, or population organizes, schedules, and establish efficient and supportive habits and routines to
prioritizes certain activities (Uyeshiro Simon & Collins, 2017). achieve health outcomes, fulfill their perceived roles and
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identity, and determine whether their roles reinforce their foundation for understanding performance (Fisher &
values and beliefs. Marterella, 2019).
Rituals are symbolic actions with spiritual, cultural, or Performance skills can be analyzed for all occupations
social meaning. Rituals contribute to a client’s identity and with clients of any age and level of ability, regardless of the
reinforce the client’s values and beliefs (Fiese, 2007; Segal, setting in which occupational therapy services are
2004). Some rituals (e.g., those associated with certain provided (Fisher & Marterella, 2019). Motor and process
holidays) are associated with different seasons or times of skills are seen during performance of an activity that
the year (e.g., New Year’s Eve, Independence Day), involves the use of tangible objects, and social

whereas others are associated with times of the day or days interaction skills are seen in any situation in which a
of the week (e.g., daily prayers, weekly family dinners). person is interacting with others:
Performance patterns are influenced by all other n Motor skills refer to how effectively a person moves
aspects of the occupational therapy domain and develop self or interacts with objects, including positioning the
over time. Occupational therapy practitioners who body, obtaining and holding objects, moving self and
consider clients’ past and present behavioral and objects, and sustaining performance.
performance patterns are better able to understand the n Process skills refer to how effectively a person
frequency and manner in which performance skills and organizes objects, time, and space, including
healthy and unhealthy occupations are, or have been, sustaining performance, applying knowledge,
integrated into clients’ lives. Although clients may have the organizing timing, organizing space and objects, and
ability to engage in skilled performance, if they do not adapting performance.
embed essential skills in a productive set of engagement n Social interaction skills refer to how effectively a
patterns, their health, well-being, and participation may be person uses both verbal and nonverbal skills to
negatively affected. For example, a person may have communicate, including initiating and terminating,
skills associated with proficient health literacy but not producing, physically supporting, shaping content of,
embed them into consistent routines (e.g., a dietitian who maintaining flow of, verbally supporting, and adapting
consistently chooses to eat fast food rather than prepare social interaction.
a healthy meal) or struggle with modifying daily
performance patterns to access health systems effectively For example, when a client catches a ball, the
(e.g., a nurse who struggles to modify work hours to get a practitioner can analyze how effectively they bend and
routine mammogram). reach for and then grasp the ball (motor skills). When a
client cooks a meal, the practitioner can analyze how
Performance Skills effectively they initiate and sequence the steps to
Performance skills are observable, goal-directed actions complete the recipe in a logical order to prepare the meal
and consist of motor skills, process skills, and social in a timely and well-organized manner (process skills). Or
interaction skills (Fisher & Griswold, 2019; Table 7). The when a client interacts with a friend at work, the
occupational therapist evaluates and analyzes practitioner can analyze the manner in which the client
performance skills during actual performance to smiles, gestures, turns toward the friend, and responds to
understand a client’s ability to perform an activity (i.e., questions (social interaction skills). In these examples,
smaller aspect of the larger occupation) in natural many other motor skills, process skills, and social
contexts (Fisher & Marterella, 2019). This evaluation interaction skills are also used by the client.
requires analysis of the quality of the individual actions By analyzing the client’s performance within an
(performance skills) during actual performance. occupation at the level of performance skills, the
Regardless of the client population, the performance skills occupational therapist identifies effective and ineffective
defined in this document are universal and provide the use of skills (Fisher & Marterella, 2019). The result of this
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analysis indicates not only whether the person is able to services. To plan appropriate interventions, the
complete an activity safely and independently but also practitioner considers the underlying reasons for the gaps,
the amount of physical effort and efficiency the client which may involve performance skills, performance
demonstrates in activities. patterns, and client factors. The hypothesis is generated
After the quality of occupational performance skills has on the basis of what the practitioner analyzes when the
been analyzed, the practitioner speculates about the client is actually performing occupations.
reasons for decreased quality of occupational Regardless of the client population, the universal
performance and determines the need to evaluate performance skills defined in this section provide the

potential underlying causes (e.g., occupational demands, foundations for understanding performance (Fisher &
environmental factors, client factors; Fisher & Griswold, Marterella, 2019). The following example crosses many
2019). Performance skills are different from client factors client populations. The practitioner observes as a client
(see the “Client Factors” section that follows), which rushes through the steps of an activity toward completion.
include values, beliefs, and spirituality and body On the basis of what the client does, the practitioner may
structures and functions (e.g., memory, strength) that interpret this rushing as resulting from a lack of impulse
reside within the person. Occupational therapy control. This limitation may be seen in clients living with
practitioners analyze performance skills as a client anxiety, attention deficit hyperactivity disorder, dementia,
performs an activity, whereas client factors cannot be traumatic brain injury, and other clinical conditions. The
directly viewed during the performance of occupations. behavior of rushing may be captured in motor performance
For example, the occupational therapy practitioner skills of manipulates, coordinates, or calibrates; in process
cannot directly view the client factors of cognitive ability or performance skills of paces, initiates, continues, or
memory when a client is engaged in cooking but rather organizes; or in social interaction performance skills of
notes ineffective use of performance skills when the takes turn, transitions, times response, or times duration.
person hesitates to start a step or performs steps in an Understanding the client’s specific occupational challenges
illogical order. The practitioner may then infer that a enables the practitioner to determine the suitable
possible reason for the client’s hesitation may be intervention to address impulsivity to facilitate greater
diminished memory and elect to further assess the client occupational performance. Clinical interventions then
factor of cognition. address the skills required for the client’s specific
Similarly, context influences the quality of a client’s occupational demands on the basis of their alignment with
occupational performance. After analyzing the client’s the universal performance skills (Fisher & Marterella, 2019).
performance skills while completing an activity, the Thus, the application of universal performance skills guides
practitioner can hypothesize how the client factors and practitioners in developing the intervention plan for specific
context might have influenced the client’s performance. clients to address the specific concerns occurring in the
Thus, client factors and contexts converge and may specific practice setting.
support or limit a person’s quality of occupational
performance. Application of Performance Skills With Groups
Analysis of performance skills is always focused on
Application of Performance Skills With Persons individuals (Fisher & Marterella, 2019). Thus, when
When completing the analysis of occupational analyzing performance skills with a group client, the
performance (described in the “Evaluation” section later in occupational therapist always focuses on one individual
this document), the practitioner analyzes the client’s at a time (Table 8). The therapist may choose to analyze
challenges in performance and generates a hypothesis some or all members of the group engaging in relevant
about gaps between current performance and effective group occupations over time as the group members
performance and the need for occupational therapy contribute to the collective actions of the group.
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If all members demonstrate effective performance be adversely affected. It is through this interactive
skills, then the group client may achieve its collective relationship that occupations and interventions to support
outcomes. If one or more group members demonstrate occupations can be used to address client factors and vice
ineffective performance skills, the collective outcomes versa.
may be diminished. Only in cases in which group Values, beliefs, and spirituality influence clients’
members demonstrate ongoing limitations in motivation to engage in occupations and give their life or
performance skills that hinder the collective outcomes of existence meaning. Values are principles, standards, or
the group would the practitioner recommend interventions qualities considered worthwhile by the client who holds

for individual group members. Interventions would then them. A belief is “something that is accepted, considered
be directed at those members demonstrating diminished to be true, or held as an opinion” (“Belief,” 2020).
performance skills to facilitate their contributions to the Spirituality is “a deep experience of meaning brought
collective group outcomes. about by engaging in occupations that involve the
enacting of personal values and beliefs, reflection, and
Application of Performance Skills With Populations intention within a supportive contextual environment”
Using an occupation-based approach to population (Billock, 2005, p. 887). It is important to recognize
health, occupational therapy addresses the needs of spirituality “as dynamic and often evolving” (Humbert,
populations by enhancing occupational performance 2016, p. 12).
and participation for communities of people (see “Service Body functions and body structures refer to the
Delivery” in the “Process” section). Service delivery to “physiological function of body systems (including
populations focuses on aggregates of people rather than psychological functions) and anatomical parts of the
on intervention for persons or groups; thus, it is not body such as organs, limbs, and their components,”
relevant to analyze performance skills at the person level respectively (WHO, 2008, p. 10). Examples of body
in service delivery to populations. functions include sensory, musculoskeletal, mental
(affective, cognitive, perceptual), cardiovascular,
Client Factors respiratory, and endocrine functions. Examples of body
Client factors are specific capacities, characteristics, or structures include the heart and blood vessels that
beliefs that reside within the person, group, or population support cardiovascular function. Body structures and
and influence performance in occupations (Table 9). body functions are interrelated, and occupational therapy
Client factors are affected by the presence or absence of practitioners consider them when seeking to promote
illness, disease, deprivation, and disability, as well as by clients’ ability to engage in desired occupations.
life stages and experiences. These factors can affect Occupational therapy practitioners understand that the
performance skills (e.g., a client may have weakness in presence, absence, or limitation of specific body functions
the right arm [a client factor], affecting their ability to and body structures does not necessarily determine a
manipulate a button [a motor and process skill] to button client’s success or difficulty with daily life occupations.
a shirt; a child in a classroom may be nearsighted [a client Occupational performance and client factors may benefit
factor], affecting their ability to copy from a chalkboard [a from supports in the physical, social, or attitudinal
motor and process skill]). contexts that enhance or allow participation. It is through
In addition, client factors are affected by occupations, the process of assessing clients as they engage in
contexts, performance patterns, and performance skills. occupations that practitioners are able to determine the
For example, a client in a controlled and calm transaction between client factors and performance skills;
environment might be able to problem solve to complete an to create adaptations, modifications, and remediation; and
occupation or activity, but when they are in a louder, more to select occupation-based interventions that best
chaotic environment, their ability to process and plan may promote enhanced participation.
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Exhibit 2. Operationalizing the Occupational Therapy Process

Ongoing interaction among evaluation, intervention, and outcomes occurs throughout the occupational therapy process.
Evaluation
Occupational Profile
• Identify the following:
◦ Why is the client seeking services, and what are the client’s current concerns relative to engaging in occupations and in daily
life activities?
◦ In what occupations does the client feel successful, and what barriers are affecting their success in desired occupations?
◦ What is the client’s occupational history (i.e., life experiences)?
◦ What are the client’s values and interests?

◦ What aspects of their contexts (environmental and personal factors) does the client see as supporting engagement in desired
occupations, and what aspects are inhibiting engagement?
◦ How are the client’s performance patterns supporting or limiting occupational performance and engagement?
◦ What are the client’s patterns of engagement in occupations, and how have they changed over time?
◦ What client factors does the client see as supporting engagement in desired occupations, and what aspects are inhibiting
engagement (e.g., pain, active symptoms)?
◦ What are the client’s priorities and desired targeted outcomes related to occupational performance, prevention, health and
wellness, quality of life, participation, role competence, well-being, and occupational justice?
Analysis of Occupational Performance

• The analysis of occupational performance involves one or more of the following:
◦ Synthesizing information from the occupational profile to determine specific occupations and contexts that need to be
addressed
◦ Completing an occupational or activity analysis to identify the demands of occupations and activities on the client
◦ Selecting and using specific assessments to measure the quality of the client’s performance or performance deficits while
completing occupations or activities relevant to desired occupations, noting the effectiveness of performance skills and
performance patterns
◦ Selecting and using specific assessments to measure client factors that influence performance skills and performance patterns
◦ Selecting and administering assessments to identify and measure more specifically the client’s contexts and their impact on
occupational performance.
Synthesis of Evaluation Process

•This synthesis may include the following:
◦ Determining the client’s values and priorities for occupational participation
◦ Interpreting the assessment data to identify supports and hindrances to occupational performance
◦ Developing and refining hypotheses about the client’s occupational performance strengths and deficits
◦ Considering existing support systems and contexts and their ability to support the intervention process
◦ Determining desired outcomes of the intervention
◦ Creating goals in collaboration with the client that address the desired outcomes
◦ Selecting outcome measures and determining procedures to measure progress toward the goals of intervention, which may
include repeating assessments used in the evaluation process.
Intervention
Intervention Plan
• Develop the plan, which involves selecting
◦ Objective and measurable occupation-based goals and related time frames;
◦ Occupational therapy intervention approach or approaches, such as create or promote, establish or restore, maintain, modify,
or prevent; and
◦ Methods for service delivery, including what types of intervention will be provided, who will provide the interventions, and
which service delivery approaches will be used.
• Consider potential discharge needs and plans.
• Make recommendations or referrals to other professionals as needed.
(Continued)
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Exhibit 2. Operationalizing the Occupational Therapy Process (cont’d)
Intervention Implementation
• Select and carry out the intervention or interventions, which may include the following:
◦ Therapeutic use of occupations and activities
◦ Interventions to support occupations
◦ Education
◦ Training
◦ Advocacy
◦ Self-advocacy

◦ Group intervention
◦ Virtual interventions.
• Monitor the client’s response through ongoing evaluation and reevaluation.
Intervention Review
• Reevaluate the plan and how it is implemented relative to achieving outcomes.
• Modify the plan as needed.
• Determine the need for continuation or discontinuation of services and for referral to other services.
Outcomes
Outcomes
• Select outcome measures early in the occupational therapy process (see the “Evaluation” section of this table) on the basis of their
properties:
◦ Valid, reliable, and appropriately sensitive to change in clients’ occupational performance
◦ Consistent with targeted outcomes
◦ Congruent with the client’s goals
◦ Able to predict future outcomes.
• Use outcome measures to measure progress and adjust goals and interventions by
◦ Comparing progress toward goal achievement with outcomes throughout the intervention process and
◦ Assessing outcome use and results to make decisions about the future direction of intervention (e.g., continue, modify,
transition, discontinue, provide follow-up, refer for other service).
Client factors can also be understood as pertaining to The occupational therapy process is the client-
group and population clients and may be used to help centered delivery of occupational therapy services. The
define the group or population. Although client factors three-part process includes (1) evaluation and (2)
may be described differently when applied to a group or intervention to achieve (3) targeted outcomes and occurs
population, the underlying principles do not change within the purview of the occupational therapy domain
substantively. Client factors of a group or population are (Table 10). The process is facilitated by the distinct
explored by performing needs assessments, and perspective of occupational therapy practitioners
interventions might include program development and engaging in professional reasoning, analyzing
strategic planning to help the members engage in occupations and activities, and collaborating with clients.
occupations. The cornerstones of occupational therapy practice
underpin the process of service delivery.
Process
Overview of the Occupational Therapy Process
This section operationalizes the process undertaken by Many professions use a similar process of evaluating,
occupational therapy practitioners when providing intervening, and targeting outcomes. However, only
services to clients. Exhibit 2 summarizes the aspects of occupational therapy practitioners focus on the
the occupational therapy process. therapeutic use of occupations to promote health, well-
GUIDELINES
being, and participation in life. Practitioners use with a student in a school, a group of practitioners
professional reasoning to select occupations as primary collaborating to develop community-based mental
methods of intervention throughout the process. To help health programming in their region) or outside the
clients achieve desired outcomes, practitioners facilitate profession (e.g., a team of rehabilitation and medical
interactions among the clients, their contexts, and the professionals on an inpatient hospital unit; a group of
occupations in which they engage. This perspective is employees, human resources staff, and health and
based on the theories, knowledge, and skills generated safety professionals in a large organization working
and used by the profession and informed by available with an occupational therapy practitioner on workplace

evidence. wellness initiatives).
Analyzing occupational performance requires an Regardless of the service delivery approach, the
understanding of the complex and dynamic interaction individual client may not be the exclusive focus of the
among the demands of the occupation and the client’s occupational therapy process. For example, the needs of
contexts, performance patterns, performance skills, an at-risk infant may be the initial impetus for intervention,
and client factors. Occupational therapy practitioners but the concerns and priorities of the parents, extended
fully consider each aspect of the domain and gauge the family, and funding agencies are also considered.
influence of each on the others, individually and Occupational therapy practitioners understand and focus
collectively. By understanding how these aspects intervention to include the issues and concerns
influence one another, practitioners can better surrounding the complex dynamics among the client,
evaluate how each aspect contributes to clients’ caregiver, family, and community. Similarly, services
participation and performance-related concerns and addressing independent living skills for adults coping
potentially to interventions that support occupational with serious mental illness or chronic health conditions
performance and participation. may also address the needs and expectations of
The occupational therapy process is fluid and state and local service agencies and of potential
dynamic, allowing practitioners and clients to maintain employers.
their focus on the identified outcomes while continually Direct Services. Services are provided directly to
reflecting on and changing the overall plan to clients using a collaborative approach in settings such as
accommodate new developments and insights along the hospitals, clinics, industry, schools, homes, and
way, including information gained from inter- and communities. Direct services include interventions
intraprofessional collaborations. The process may be completed when in direct contact with the client through
influenced by the context of service delivery (e.g., setting, various mechanisms such as meeting in person, leading a
payer requirements); however, the primary focus is group session, and interacting with clients and families
always on occupation. through telehealth systems (AOTA, 2018c).
Examples of person-level direct service delivery
Service Delivery Approaches include working with an adult on an inpatient rehabilitation
Various service delivery approaches are used when unit, working with a child in the classroom while
providing skilled occupational therapy services, of collaborating with the teacher to address identified goals,
which intra- and interprofessional collaborations are a and working with an adolescent in an outpatient setting.
key component. It is imperative to communicate with all Direct group interventions include working with a cooking
relevant providers and stakeholders to ensure a group in a skilled nursing facility, working with an
collaborative approach to the occupational therapy outpatient feeding group, and working with a handwriting
process. These providers and stakeholders can be group in a school. Examples of population-level direct
within the profession (e.g., occupational therapist and services include implementing a large-scale healthy
occupational therapy assistant collaborating to work lifestyle or safe driver initiative in the community and
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delivering a training program for brain injury treatment Additional Approaches. Occupational therapy
facilities regarding safely accessing public transportation. practitioners use additional approaches that may also be
An occupational therapy approach to population health classified as direct or indirect for persons, groups, and
focuses on aggregates or communities of people and the populations. Examples include, but are not limited to,
many factors that influence their health and well-being: case management (AOTA, 2018b), telehealth (AOTA,
“Occupational therapy practitioners develop and 2018c), episodic care (Centers for Medicare & Medicaid
implement occupation-based health approaches to Services, 2019), and family-centered care approaches
enhance occupational performance and participation, (Hanna & Rodger, 2002).

[quality of life], and occupational justice for populations”
(AOTA, 2020b, p. 3). Practice Within Organizations and Systems
Indirect Services. When providing services to clients Organization- or systems-level practice is a valid and
indirectly on their behalf, occupational therapy important part of occupational therapy for several reasons.
practitioners provide consultation to entities such as First, organizations serve as a mechanism through which
teachers, multidisciplinary teams, and community occupational therapy practitioners provide interventions
planning agencies. For example, a practitioner may to support participation of people who are members of or
consult with a group of elementary school teachers and served by the organization (e.g., falls prevention
administrators about opportunities for play during programming in a skilled nursing facility, ergonomic
recess to promote health and well-being. A practitioner changes to an assembly line to reduce musculoskeletal
may also provide consultation on inclusive design to a disorders). Second, organizations support occupational
park district or civic organization to address how the therapy practice and practitioners as stakeholders in
built and natural environments can support occupa- carrying out the mission of the organization. Practitioners
tional performance and engagement. In addition, a have the responsibility to ensure that services provided
practitioner may consult with a business regarding the to organizational stakeholders (e.g., third-party payers,
work environment, ergonomic modifications, and employers) are of high quality and delivered in an ethical,
compliance with the Americans With Disabilities Act of efficient, and efficacious manner.
1990 (Pub. L. 101-336). Finally, organizations employ occupational therapy
Occupational therapy practitioners can advocate practitioners in roles in which they use their knowledge of
indirectly on behalf of their clients at the person, group, occupation and the profession of occupational therapy
and population levels to ensure their occupational indirectly. For example, practitioners can serve in
needs are met. For example, an occupational therapy positions such as dean, administrator, and corporate
practitioner may advocate for funding to support the leader (e.g., CEO, business owner). In these positions,
costs of training a service animal for an individual practitioners support and enhance the organization but
client. A practitioner working with a group client may do not provide occupational therapy services in the
advocate for meeting space in the community for a peer traditional sense. Occupational therapy practitioners can
support group of transgender youth. Examples of also serve organizations in roles such as client advocate,
population-level advocacy include talking with program coordinator, transition manager, service or care
legislators about improving transportation for older coordinator, health and wellness coach, and community
adults, developing services for people with disabilities integration specialist.
to support their living and working in the community of
their choice, establishing meaningful civic engagement Occupational and Activity Analysis
opportunities for underserved youth, and assisting in Occupational therapy practitioners are skilled in the
the development of policies that address inequities in analysis of occupations and activities and apply this
access to health care. important skill throughout the occupational therapy
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process. Occupational analysis is performed with an intervention. The collaborative approach used
understanding of “the specific situation of the client and throughout the process honors the contributions of
therefore . . . the specific occupations the client wants or clients along with practitioners. Through the use of
needs to do in the actual context in which these interpersonal communication skills, practitioners shift
occupations are performed” (Schell et al., 2019, p. 322). In the power of the relationship to allow clients more
contrast, activity analysis is generic and control in decision making and problem solving, which is
decontextualized in its purpose and serves to develop an essential to effective intervention. Clients have
understanding of typical activity demands within a given identified the therapeutic relationship as critical to the

culture. Many professions use activity analysis, whereas outcome of occupational therapy intervention (Cole &
occupational analysis requires the understanding of McLean, 2003).
occupation as distinct from activity and brings an Clients bring to the occupational therapy process
occupational therapy perspective to the analysis process their knowledge about their life experiences and their
(Schell et al., 2019). hopes and dreams for the future. They identify and
Occupational therapy practitioners analyze the share their needs and priorities. Occupational therapy
demands of an occupation or activity to understand the practitioners must create an inclusive, supportive
performance patterns, performance skills, and client environment to enable clients to feel safe in expressing
factors that are required to perform it (Table 11). themselves authentically. To build an inclusive
Depending on the purpose of the analysis, the meaning environment, practitioners can take actions such as
ascribed to and the contexts for performance of and pursuing education on gender-affirming care,
engagement in the occupation or activity are considered acknowledging systemic issues affecting
either from a client-specific subjective perspective underrepresented groups, and using a lens of cultural
(occupational analysis) or a general perspective within a humility throughout the occupational therapy process
given culture (activity analysis). (AOTA, 2020c; Hammell, 2013).
Occupational therapy practitioners bring to the
Therapeutic Use of Self therapeutic relationship their knowledge about how
An integral part of the occupational therapy process is engagement in occupation affects health, well-being,
therapeutic use of self, in which occupational therapy and participation; they use this information, coupled
practitioners develop and manage their therapeutic with theoretical perspectives and professional
relationship with clients by using professional reasoning, to critically evaluate, analyze, describe,
reasoning, empathy, and a client-centered, collaborative and interpret human performance. Practitioners and
approach to service delivery (Taylor & Van clients, together with caregivers, family members,
Puymbrouck, 2013). Occupational therapy practitioners community members, and other stakeholders (as
use professional reasoning to help clients make sense of appropriate), identify and prioritize the focus of the
the information they are receiving in the intervention intervention plan.
process, discover meaning, and build hope (Taylor,
2019; Taylor & Van Puymbrouck, 2013). Empathy is the Clinical and Professional Reasoning
emotional exchange between occupational therapy Throughout the occupational therapy process,
practitioners and clients that allows more open practitioners are continually engaged in clinical and
communication, ensuring that practitioners connect with professional reasoning about a client’s occupational
clients at an emotional level to assist them with their performance. The term professional reasoning is used
current life situation. throughout this document as a broad term to encompass
Practitioners develop a collaborative relationship with reasoning that occurs in all settings (Schell, 2019).
clients to understand their experiences and desires for Professional reasoning enables practitioners to
GUIDELINES
n Identify the multiple demands, required skills, and focuses on collecting and interpreting information
potential meanings of the activities and occupations specifically to identify supports and barriers related to
and occupational performance and establish targeted
n Gain a deeper understanding of the interrelationships outcomes.
among aspects of the domain that affect performance Although the OTPF–4 describes the components of the
and that support client-centered interventions and evaluation process separately and sequentially, the exact
outcomes. manner in which occupational therapy practitioners
collect client information is influenced by client needs,
Occupational therapy practitioners use theoretical

practice settings, and frames of reference or practice
principles and models, knowledge about the effects of
models. The evaluation process for groups and
conditions on participation, and available evidence on
populations mirrors that for individual clients.
the effectiveness of interventions to guide their reasoning.
In some settings, the occupational therapist first
Professional reasoning ensures the accurate selection
completes a screening or consultation to determine the
and application of client-centered evaluation methods,
appropriateness of a full occupational therapy evaluation
interventions, and outcome measures. Practitioners also
(Hinojosa et al., 2014). This process may include
apply their knowledge and skills to enhance clients’
participation in occupations and promote their health and n Review of client history (e.g., medical, health, social,
well-being regardless of the effects of disease, disability, or academic records),
and occupational disruption or deprivation. n Consultation with an interprofessional or referring
team, and
n Use of standardized or structured screening
Evaluation
instruments.
The evaluation process is focused on finding out what
the client wants and needs to do; determining what the
The screening or consultation process may result in
client can do and has done; and identifying supports and
the development of a brief occupational profile and
barriers to health, well-being, and participation. Evaluation
recommendations for full occupational therapy
occurs during the initial and all subsequent interactions
evaluation and intervention (Hinojosa et al., 2014).
with a client. The type and focus of the evaluation differ
depending on the practice setting; however, all evaluations
Occupational Profile
should assess the complex and multifaceted needs of each The occupational profile is a summary of a client’s
client. (person’s, group’s, or population’s) occupational history
The evaluation consists of the occupational profile and and experiences, patterns of daily living, interests,
the analysis of occupational performance, which are values, needs, and relevant contexts (AOTA, 2017a).
synthesized to inform the intervention plan (Hinojosa Developing the occupational profile provides the
et al., 2014). Although it is the responsibility of the occupational therapy practitioner with an understanding
occupational therapist to initiate the evaluation process, of the client’s perspective and background.
both occupational therapists and occupational therapy Using a client-centered approach, the occupational
assistants may contribute to the evaluation, following therapy practitioner gathers information to understand what
which the occupational therapist completes the analysis is currently important and meaningful to the client (i.e., what
and synthesis of information for the development of the the client wants and needs to do) and to identify past
intervention plan (AOTA, 2020a). The occupational experiences and interests that may assist in the
profile includes information about the client’s needs, understanding of current issues and problems. During the
problems, and concerns about performance in process of collecting this information, the client, with the
occupations. The analysis of occupational performance assistance of the practitioner, identifies priorities and desired
GUIDELINES
targeted outcomes that will lead to the client’s engagement n In what occupations does the client feel successful,
in occupations that support participation in daily life. Only and what barriers are affecting their success in
clients can identify the occupations that give meaning to their desired occupations?
lives and select the goals and priorities that are important to n What is the client’s occupational history (i.e., life
them. By valuing and respecting clients’ input, practitioners experiences)?
help foster their involvement and can more effectively guide n What are the client’s values and interests?
interventions. n What aspects of their contexts (environmental and
Occupational therapy practitioners collect information personal factors) does the client see as supporting

for the occupational profile at the beginning of contact with engagement in desired occupations, and what
clients to establish client-centered outcomes. Over time, aspects are inhibiting engagement?
practitioners collect additional information, refine the n How are the client’s performance patterns supporting
profile, and ensure that the additional information is or limiting occupational performance and
reflected in changes subsequently made to targeted engagement?
outcomes. The process of completing and refining the n What are the client’s patterns of engagement in
occupational profile varies by setting and client and may occupations, and how have they changed over time?
occur continuously throughout the occupational therapy n What client factors does the client see as supporting
process. engagement in desired occupations, and what aspects
Information gathering for the occupational profile may are inhibiting engagement (e.g., pain, active
be completed in one session or over a longer period while symptoms)?
working with the client. For clients who are unable to n What are the client’s priorities and desired targeted
participate in this process, their profile may be compiled outcomes related to occupational performance,
through interaction with family members or other significant prevention, health and wellness, quality of life,
people in their lives. Information for the occupational participation, role competence, well-being, and
profile may also be gathered from available and relevant occupational justice?
records.
Obtaining information for the occupational profile After the practitioner collects profile data, the
through both formal and informal interview techniques and occupational therapist views the information and develops
conversation is a way to establish a therapeutic a working hypothesis regarding possible reasons for the
relationship with clients and their support network. identified problems and concerns. Reasons could include
Techniques used should be appropriate and reflective of impairments in performance skills, performance patterns,
clients’ preferred method and style of communication or client factors or barriers within relevant contexts. In
(e.g., use of a communication board, translation addition, the therapist notes the client’s strengths and
services). Practitioners may use AOTA’s Occupational supports in all areas because these can inform the
Profile Template as a guide to completing the intervention plan and affect targeted outcomes.
occupational profile (AOTA, 2017a). The information
obtained through the occupational profile contributes to an Analysis of Occupational Performance
individualized approach in the evaluation, intervention Occupational performance is the accomplishment of the
planning, and intervention implementation stages. selected occupation resulting from the dynamic transaction
Information is collected in the following areas: among the client, their contexts, and the occupation. In the
analysis of occupational performance, the practitioner
n Why is the client seeking services, and what are the identifies the client’s ability to effectively complete desired
client’s current concerns relative to engaging in occupations. The client’s assets and limitations or potential
occupations and in daily life activities? problems are more specifically determined through
GUIDELINES
assessment tools designed to analyze, measure, and inquire (Doucet & Gutman, 2013; Hinojosa & Kramer, 2014). In
about factors that support or hinder occupational addition, the use of standardized outcome performance
performance. measures and outcome tools assists in establishing a
Multiple methods often are used during the evaluation baseline of occupational performance to allow for objective
process to assess the client, contexts, occupations, and measurement of progress after intervention.
occupational performance. Methods may include
Synthesis of the Evaluation Process
observation and analysis of the client’s performance of
The occupational therapist synthesizes the information
specific occupations and assessment of specific aspects
gathered through the occupational profile and analysis of

of the client or their performance. The approach to the
occupational performance. This process may include the
analysis of occupational performance is determined by
following:
the information gathered through the occupational profile
and influenced by models of practice and frames of n Determining the client’s values and priorities for
reference appropriate to the client and setting. The occupational participation
analysis of occupational performance involves one or n Interpreting the assessment data to identify supports
more of the following: and hindrances to occupational performance
n Developing and refining hypotheses about the
n Synthesizing information from the occupational
client’s occupational performance strengths and
profile to determine specific occupations and
deficits
contexts that need to be addressed n Considering existing support systems and contexts
n Completing an occupational or activity analysis to
and their ability to support the intervention process
identify the demands of occupations and activities on n Determining desired outcomes of the intervention
the client n Creating goals in collaboration with the client that
n Selecting and using specific assessments to
address the desired outcomes
measure the quality of the client’s performance or n Selecting outcome measures and determining
performance deficits while completing occupations or
procedures to measure progress toward the goals of
activities relevant to desired occupations, noting the
intervention, which may include repeating
effectiveness of performance skills and performance assessments used in the evaluation process.
patterns
n Selecting and using specific assessments to Any outcome assessment used by occupational
measure client factors that influence performance therapy practitioners must be consistent with clients’
skills and performance patterns belief systems and underlying assumptions regarding
n Selecting and administering assessments to identify their desired occupational performance. Occupational
and measure more specifically the client’s contexts
therapy practitioners select outcome assessments
and their impact on occupational performance.
pertinent to clients’ needs and goals, congruent with
Occupational performance may be measured through the practitioner’s theoretical model of practice.
standardized, formal, and structured assessment tools, and Assessment selection is also based on the practitioner’s
when necessary informal approaches may also be used knowledge of and available evidence for the
(Asher, 2014). Standardized assessments are preferred, psychometric properties of standardized measures or the
when available, to provide objective data about various rationale and protocols for nonstandardized structured
aspects of the domain influencing engagement and measures. In addition, clients’ perception of success in
performance. The use of valid and reliable assessments engaging in desired occupations is a vital part of outcome
for obtaining trustworthy information can also help support assessment (Bandura, 1986). The occupational therapist
and justify the need for occupational therapy services uses the synthesis and summary of information from the
GUIDELINES
evaluation and established targeted outcomes to guide the referred to as a patient or patients, and in a school, the
intervention process. clients might be students. Early intervention requires
practitioners to work with the family system as their
Intervention clients. When practitioners provide consultation to an
The intervention process consists of services provided by organization, clients may be called consumers or
occupational therapy practitioners in collaboration with members. Terms used for others who may help or be
clients to facilitate engagement in occupation related to served indirectly include, but are not limited to,
health, well-being, and achievement of established goals caregiver, teacher, parent, employer, or spouse.

consistent with the various service delivery models. Intervention can also be in the form of collective
Practitioners use the information about clients gathered services to groups and populations. Such intervention
during the evaluation and theoretical principles to select can occur as direct service provision or consultation.
and provide occupation-based interventions to assist When consulting with an organization, occupational
clients in achieving physical, mental, and social well- therapy practitioners may use strategic planning, change
being; identifying and realizing aspirations; satisfying agent plans, and other program development
needs; and changing or coping with contextual factors. approaches. Practitioners addressing the needs of a
Types of occupational therapy interventions are population direct their interventions toward current or
categorized as occupations and activities, interventions to potential diseases or conditions with the goal of
support occupations, education and training, advocacy, enhancing the health, well-being, and participation of all
group interventions, and virtual interventions (Table 12). members collectively. With groups and populations, the
Approaches to intervention include create or promote, intervention focus is often on health promotion,
establish or restore, maintain, modify, and prevent prevention, and screening. Interventions may include
(Table 13). Across all types of and approaches to (but are not limited to) self-management training,
interventions, it is imperative that occupational therapy educational services, and environmental modification. For
practitioners maintain an understanding of the instance, occupational therapy practitioners may provide
Occupational Therapy Code of Ethics (AOTA, 2015a) education on falls prevention and the impact of fear of
and the Standards of Practice for Occupational Therapy falling to residents in an assisted living center or training to
(AOTA, 2015c). people facing a mental health challenge in use of the
Intervention is intended to promote health, well-being, internet to identify and coordinate community resources
and participation. Health promotion is “the process of that meet their needs.
enabling people to increase control over, and to improve, Occupational therapy practitioners work with a
their health” (WHO, 1986). Wilcock (2006) stated, wide variety of populations experiencing difficulty in
accessing and engaging in healthy occupations because
Following an occupation-based health promotion approach to well-being of factors such as poverty, homelessness, displacement,
embraces a belief that the potential range of what people can do, be, and
strive to become is the primary concern, and that health is a by-product.
and discrimination. For example, practitioners can
A varied and full occupational lifestyle will coincidentally maintain and work with organizations providing services to
improve health and well-being if it enables people to be creative and
adventurous physically, mentally, and socially. (p. 315)
refugees and asylum seekers to identify opportunities to
reestablish occupational roles and enhance well-being and
Interventions vary depending on the client—person, quality of life.
group, or population—and the context of service delivery. The intervention process is divided into three
The actual term used for clients or groups of clients components: (1) intervention plan, (2) intervention
receiving occupational therapy varies among practice implementation, and (3) intervention review. During the
settings and delivery models. For example, when intervention process, the occupational therapy practitioner
working in a hospital, the person or group might be integrates information from the evaluation with theory,
GUIDELINES
practice models, frames of reference, and research + Occupational therapy intervention approach or
evidence on interventions, including those that support approaches; and
occupations. This information guides the practitioner’s + Methods for service delivery, including what types of
professional reasoning in intervention planning, interventions will be provided, who will provide the
implementation, and review. Because evaluation is interventions, and which service delivery
ongoing, revision may occur at any point during the approaches will be used;
intervention process. 2. Considering potential discharge needs and plans; and
3. Making recommendations or referrals to other

professionals as needed.
Intervention Plan
The intervention plan, which directs the actions of
Steps 2 and 3 are discussed in the Outcomes section.
occupational therapy practitioners, describes the
occupational therapy approaches and types of
interventions selected for use in reaching clients’ targeted
outcomes. The intervention plan is developed Intervention Implementation
collaboratively with clients or their proxies and is directed Intervention implementation is the process of putting
by the intervention plan into action and occurs after the
initial evaluation process and development of the
n Client goals, values, beliefs, and occupational needs
intervention plan. Interventions may focus on a single
and
aspect of the occupational therapy domain, such as a
n Client health and well-being,
specific occupation, or on several aspects of the
as well as by the practitioners’ evaluation of
domain, such as contexts, performance patterns, and
n Client occupational performance needs;
performance skills, as components of one or more
n Collective influence of the contexts, occupational or
activity demands, and client factors on the client; occupations. Intervention implementation must always
n Client performance skills and performance reflect the occupational therapy scope of practice;
patterns; occupational practitioners should not perform
n Context of service delivery in which the intervention is interventions that do not use purposeful and
provided; and occupation-based approaches (Gillen et al., 2019).
n Best available evidence. Intervention implementation includes the following
steps (see Table 12):
The occupational therapist designs the intervention n Select and carry out the intervention or
plan on the basis of established treatment goals, interventions, which may include the following:
addressing the client’s current and potential situation + Therapeutic use of occupations and activities
related to engagement in occupations or activities. The + Interventions to support occupations
intervention plan should reflect the priorities of the client, + Education
information on occupational performance gathered + Training
through the evaluation process, and targeted outcomes + Advocacy
of the intervention. Intervention planning includes the + Self-advocacy
following steps: + Group intervention
1. Developing the plan, which involves selecting + Virtual interventions.
+ Objective and measurable occupation-based goals n Monitor the client’s response through ongoing
and related time frames; evaluation and reevaluation.
GUIDELINES
Given that aspects of the domain are interrelated and Results of occupational therapy services are
influence one another in a continuous, dynamic process, established using outcome performance measures and
occupational therapy practitioners expect that a client’s outcome tools.
ability to adapt, change, and develop in one area will Outcomes are directly related to the interventions
affect other areas. Because of this dynamic provided and to the targeted occupations, performance
interrelationship, evaluation, including analysis of patterns, performance skills, client factors, and
occupational performance, and intervention planning contexts. Outcomes may be traced to improvement in
continue throughout the implementation process. In areas of the domain, such as performance skills and

addition, intervention implementation includes client factors, but should ultimately be reflected in
monitoring of the client’s response to specific clients’ ability to engage in their desired occupations.
interventions and progress toward goals. Outcomes targeted in occupational therapy can be
summarized as
Intervention Review n Occupational performance,
Intervention review is the continuous process of n Prevention,
reevaluating and reviewing the intervention plan, the n Health and wellness,
effectiveness of its delivery, and progress toward n Quality of life,
outcomes. As during intervention planning, this n Participation,
process includes collaboration with the client to identify n Role competence,
progress toward goals and outcomes. Reevaluation n Well-being, and
and review may lead to change in the intervention plan. n Occupational justice.
Practitioners should review best practices for using process
Occupational adaptation, or the client’s effective and
indicators and, as appropriate, modify the intervention plan
efficient response to occupational and contextual
and monitor progress using outcome performance
demands (Grajo, 2019), is interwoven through all of
measures and outcome tools. Intervention review includes
these outcomes.
the following steps:
The impact of outcomes and the way they are defined
1. Reevaluating the plan and how it is implemented are specific to clients (persons, groups, or populations)
relative to achieving outcomes and to other stakeholders such as payers and regulators.
2. Modifying the plan as needed Outcomes and their documentation vary by practice
3. Determining the need for continuation or setting and are influenced by the stakeholders in each
discontinuation of occupational therapy services and setting (AOTA, 2018a).
for referral to other services. The focus on outcomes is woven throughout the
process of occupational therapy. During evaluation,
Outcomes occupational therapy practitioners and clients (and often
Outcomes emerge from the occupational therapy others, such as parents and caregivers) collaborate to
process and describe the results clients can achieve identify targeted outcomes related to engagement in valued
through occupational therapy intervention (Table 14). occupations or daily life activities. These outcomes are the
The outcomes of occupational therapy are basis for development of the intervention plan. During
multifaceted and may occur in all aspects of the domain intervention implementation and review, clients and
of concern. Outcomes should be measured with the practitioners may modify targeted outcomes to
same methods used at evaluation and determined accommodate changing needs, contexts, and
through comparison of the client’s status at evaluation performance abilities. Ultimately, the intervention process
with the client’s status at discharge or transition. should result in the achievement of outcomes related to
GUIDELINES
health, well-being, and participation in life through tools measure what patients are able to do and how they
engagement in occupation. feel by asking questions. These tools enable assessment
of patient-reported health status for physical, mental, and
Outcome Measurement social well-being” (National Quality Forum, n.d., para. 1).
Objective outcomes are measurable and tangible Outcomes can also be designed for caregivers—for
aspects of improved performance. Outcome example, improved quality of life for both care recipient
measurement is sometimes derived from standardized and caregiver. Studies of caregivers of people with
assessments, with results reflected in numerical data dementia who received a home environmental

following specific scoring instructions. These data quantify intervention found fewer declines in occupational
a client’s response to intervention in a way that can be performance, enhanced mastery and skill, improved
used by all relevant stakeholders. Objective outcome sense of self-efficacy and well-being, and less need for
measures are selected early in the occupational therapy help with care recipients (Gitlin & Corcoran, 2005; Gitlin
process on the basis of properties showing that they are et al., 2001, 2003, 2008; Graff et al., 2007; Piersol et al.,
n Valid, reliable, and appropriately sensitive to change 2017).
in the client’s occupational performance, Outcomes for groups that receive an educational
n Consistent with targeted outcomes, intervention may include improved social interaction,
n Congruent with the client’s goals, and increased self-awareness through peer support, a larger
n Able to predict future outcomes. social network, or improved employee health and
productivity. For example, education interventions for
Practitioners use objective outcome measures to groups of employees on safety and workplace wellness
measure progress and adjust goals and interventions by have been shown to decrease work injuries and increase
workplace productivity and satisfaction (Snodgrass & Amini,
n Comparing progress toward goal achievement with 2017).
outcomes throughout the intervention process and Outcomes for populations may address health
n Measuring and assessing results to make decisions promotion, occupational justice and self-advocacy, health
about the future direction of intervention (e.g., literacy, community integration, community living, and
continue, modify, transition, discontinue, provide access to services. As with other occupational therapy
follow-up, refer for other service). clients, outcomes for populations are focused on
In some settings, the focus is on patient-reported occupational performance, engagement, and participation.
outcomes (PROs), which have been defined as “any For example, outcomes at the population level as a result of
report of the status of a patient’s health condition that advocacy interventions include construction of accessible
comes directly from the patient, without interpretation of playground facilities, improved accessibility for polling
the patient’s response by a clinician or anyone else” places, and reconstruction of a school after a natural
(National Quality Forum, n.d., para. 1). PROs can be disaster.
used as subjective measures of improved outlook,
confidence, hope, playfulness, self-efficacy, sustainability Transition and Discontinuation
of valued occupations, pain reduction, resilience, and Transition is movement from one life role or experience to
perceived well-being. An example of a PRO is parents’ another. Transitions in services, like all life transitions,
greater perceived efficacy in parenting through a new may require preparation, new knowledge, and time to
understanding of their child’s behavior (Cohn, 2001; accommodate to the new situation (Orentlicher et al.,
Cohn et al., 2000; Graham et al., 2013). Another example 2015). Transition planning may be needed, for example,
is a report by an outpatient client with a hand injury of a when a client moves from one setting to another along
reduction in pain during the IADL of doing laundry. “PRO the care continuum (e.g., acute hospital to skilled nursing
GUIDELINES
facility) or ages out of one program and into a new one

Conclusion
(e.g., early intervention to elementary school).
Collaboration among practitioners is necessary to ensure The OTPF–4 describes the central concepts that ground
safety, well-being, and optimal outcomes for clients (Joint occupational therapy practice and builds a common
Commission, 2012, 2013). understanding of the basic tenets and distinct
Transition planning may include a referral to a provider contribution of the profession. The occupational therapy
within occupational therapy with advanced knowledge domain and process are linked inextricably in a
and skill (e.g., vestibular rehabilitation, driver evaluation,
transactional relationship. An understanding of this

hand therapy) or outside the profession (e.g.,
relationship supports and guides the complex decision
psychologist, optometrist). Transition planning for groups
making required in the daily practice of occupational
and populations may be needed for a transition from one
therapy and enhances practitioners’ ability to
stage to another (e.g., middle school students in a life
define the reasons for and justify the provision of
skills program who transition to high school) or from one
set of needs to another (e.g., older adults in a community services when communicating with clients, family
falls prevention program who transition to a community members, team members, employers, payers, and
exercise program). policymakers.
Planning for discontinuation of occupational This edition of the OTPF provides a broader view than
therapy services begins at initial evaluation. previous editions of occupational therapy as related to
Discontinuation of care occurs when the client ends groups and populations and current and future
services after meeting short- and long-term goals or occupational needs of clients. It also presents and
chooses to discontinue receiving services (consistent describes the cornerstones of occupational therapy practice,
with client-centered care). Safe and effective which are discrete and critical qualities of occupational
discharge planning for a person may include therapy practitioners that provide them with a foundation for
education on the use of new equipment, adaptation of success in the occupational therapy process. The OTPF–4
an occupation, caregiver training, environmental highlights the distinct value of occupation and occupational
modification, or determination of the appropriate
therapy in contributing to health, well-being, and participation
setting for transition of care. A key goal of discharge
in life for persons, groups, and populations. This document
planning for individual clients is prevention of
can be used to advocate for the importance of occupational
readmission (Rogers et al., 2017). Discontinuation of
therapy in meeting society’s current and future needs,
services for groups and populations occurs when goals
ultimately advancing the profession to ensure a sustainable
are met and sustainability plans are implemented for
long-term success. future.
GUIDELINES
Table 1. Examples of Clients: Persons, Groups, and Populations

Person Group Population
Health Management
Middle-school student with diabetes in- Group of students with diabetes interested All students in the school provided with
terested in developing self-management in problem solving the school setting’s access to food choices to meet varying
skills to test blood sugar levels support for management of their condition dietary needs and desires
Feeding
Family of an infant with a history of pre- Families with infants experiencing feeding Families of infants advocating for re-

maturity and difficulty accepting nutrition challenges advocating for the local hos- search and development of alternative
orally pital’s rehabilitation services to develop nipple and bottle designs to address
infant feeding classes feeding challenges
Community Mobility
Person with stroke who wants to return to Stroke support group talking with elected Stroke survivors advocating for increased
driving leaders about developing community access to community mobility options for
mobility resources all persons living with mobility limitations
Social Participation
Young adult with IDD interested in in- Young adults with IDD in a transition Young adults with IDD educating their
creasing social participation program sponsoring leisure activities in community about their need for inclusion
which all may participate in valued social in community-based social and leisure
relationships activities
Home Establishment and Management
Person living with SMI interested in de- Support group for people living with SMI People living with SMI in the same region
veloping skills for independent living developing resources to foster indepen- advocating for increased housing options
dent living for independent living
Work Participation
Older worker with difficulty performing Group of older workers in a factory ad- Older workers in a national corporation
some work tasks vocating for modification of equipment to advocating for company-wide wellness
address discomfort when operating the support programs
same set of machines
Note. IDD = intellectual and developmental disabilities; SMI = serious mental illness.
GUIDELINES
Table 2. Occupations
Occupations are “the everyday activities that people do as individuals, in families, and with communities to occupy time and bring
meaning and purpose to life. Occupations include things people need to, want to and are expected to do” (World Federation of
Occupational Therapists, 2012a, para. 2). Occupations are categorized as activities of daily living, instrumental activities of daily living,
health management, rest and sleep, education, work, play, leisure, and social participation.
Occupation Description
Activities of Daily Living (ADLs)—Activities oriented toward taking care of one’s own body and completed on a routine basis
(adapted from Rogers & Holm, 1994).
Bathing, showering Obtaining and using supplies; soaping, rinsing, and drying body

parts; maintaining bathing position; transferring to and from
bathing positions
Toileting and toilet hygiene Obtaining and using toileting supplies, managing clothing,
maintaining toileting position, transferring to and from toileting
position, cleaning body, caring for menstrual and continence
needs (including catheter, colostomy, and suppository man-
agement), maintaining intentional control of bowel movements
and urination and, if necessary, using equipment or agents
for bladder control (Uniform Data System for Medical
Rehabilitation, 1996, pp. III-20, III-24)
Dressing Selecting clothing and accessories with consideration of time of
day, weather, and desired presentation; obtaining clothing from
storage area; dressing and undressing in a sequential fashion;
fastening and adjusting clothing and shoes; applying and re-
moving personal devices, prosthetic devices, or splints
Eating and swallowing Keeping and manipulating food or fluid in the mouth, swal-
lowing it (i.e., moving it from the mouth to the stomach)
Feeding Setting up, arranging, and bringing food or fluid from the vessel
to the mouth (includes self-feeding and feeding others)
Functional mobility Moving from one position or place to another (during perfor-
mance of everyday activities), such as in-bed mobility, wheel-
chair mobility, and transfers (e.g., wheelchair, bed, car, shower,
tub, toilet, chair, floor); includes functional ambulation and
transportation of objects
Personal hygiene and grooming Obtaining and using supplies; removing body hair (e.g., using a
razor or tweezers); applying and removing cosmetics; washing,
drying, combing, styling, brushing, and trimming hair; caring
for nails (hands and feet); caring for skin, ears, eyes, and nose;
applying deodorant; cleaning mouth; brushing and flossing
teeth; removing, cleaning, and reinserting dental orthotics and
prosthetics
Sexual activity Engaging in the broad possibilities for sexual expression and
experiences with self or others (e.g., hugging, kissing, foreplay,
masturbation, oral sex, intercourse)
Instrumental Activities of Daily Living (IADLs)—Activities to support daily life within the home and community.
Care of others (including selection and supervision of caregivers) Providing care for others, arranging or supervising formal care
(by paid caregivers) or informal care (by family or friends) for
others
(Continued)
GUIDELINES
Table 2. Occupations (cont’d)
Care of pets and animals Providing care for pets and service animals, arranging or su-
pervising care for pets and service animals
Child rearing Providing care and supervision to support the developmental
and physiological needs of a child
Communication management Sending, receiving, and interpreting information using systems
and equipment such as writing tools, telephones (including

smartphones), keyboards, audiovisual recorders, computers or
tablets, communication boards, call lights, emergency systems,
Braille writers, telecommunication devices for deaf people,
augmentative communication systems, and personal digital
assistants
Driving and community mobility Planning and moving around in the community using public or
private transportation, such as driving, walking, bicycling, or
accessing and riding in buses, taxi cabs, ride shares, or other
transportation systems
Financial management Using fiscal resources, including financial transaction methods
(e.g., credit card, digital banking); planning and using finances
with long-term and short-term goals
Home establishment and management Obtaining and maintaining personal and household possessions
and environments (e.g., home, yard, garden, houseplants,
appliances, vehicles), including maintaining and repairing
personal possessions (e.g., clothing, household items) and
knowing how to seek help or whom to contact
Meal preparation and cleanup Planning, preparing, and serving meals and cleaning up food
and tools (e.g., utensils, pots, plates) after meals
Religious and spiritual expression Engaging in religious or spiritual activities, organizations, and
practices for self-fulfillment; finding meaning or religious or
spiritual value; establishing connection with a divine power,
such as is involved in attending a church, temple, mosque, or
synagogue; praying or chanting for a religious purpose; en-
gaging in spiritual contemplation (World Health Organization,
2008); may also include giving back to others, contributing to
society or a cause, and contributing to a greater purpose
Safety and emergency maintenance Evaluating situations in advance for potential safety risks;
recognizing sudden, unexpected hazardous situations and ini-
tiating emergency action; reducing potential threats to health
and safety, including ensuring safety when entering and exiting
the home, identifying emergency contact numbers, and
replacing items such as batteries in smoke alarms and light
bulbs
Shopping Preparing shopping lists (grocery and other); selecting, pur-
chasing, and transporting items; selecting method of payment
and completing payment transactions; managing internet
shopping and related use of electronic devices such as com-
puters, cell phones, and tablets
(Continued)
GUIDELINES
Health Management—Activities related to developing, managing, and maintaining health and wellness routines, including
self-management, with the goal of improving or maintaining health to support participation in other occupations.
Social and emotional health promotion and maintenance Identifying personal strengths and assets, managing emotions,
expressing needs effectively, seeking occupations and social
engagement to support health and wellness, developing self-
identity, making choices to improve quality of life in participation

Symptom and condition management Managing physical and mental health needs, including using
coping strategies for illness, trauma history, or societal stigma;
managing pain; managing chronic disease; recognizing
symptom changes and fluctuations; developing and using
strategies for managing and regulating emotions; planning time
and establishing behavioral patterns for restorative activities
(e.g., meditation); using community and social supports;
navigating and accessing the health care system
Communication with the health care system Expressing and receiving verbal, written, and digital commu-
nication with health care and insurance providers, including
understanding and advocating for self or others
Medication management Communicating with the physician about prescriptions, filling
prescriptions at the pharmacy, interpreting medication in-
structions, taking medications on a routine basis, refilling
prescriptions in a timely manner (American Occupational
Therapy Association, 2017c; Schwartz & Smith, 2017)
Physical activity Completing cardiovascular exercise, strength training, and
balance training to improve or maintain health and decrease risk
of health episodes, such as by incorporating walks into daily
routine
Nutrition management Implementing and adhering to nutrition and hydration recom-
mendations from the medical team, preparing meals to support
health goals, participating in health-promoting diet routines
Personal care device management Procuring, using, cleaning, and maintaining personal care de-
vices, including hearing aids, contact lenses, glasses, orthotics,
prosthetics, adaptive equipment, pessaries, glucometers, and
contraceptive and sexual devices
Rest and Sleep—Activities related to obtaining restorative rest and sleep to support healthy, active engagement in other
occupations.
Rest Identifying the need to relax and engaging in quiet and effortless
actions that interrupt physical and mental activity (Nurit &
Michal, 2003, p. 227); reducing involvement in taxing physical,
mental, or social activities, resulting in a relaxed state; engaging
in relaxation or other endeavors that restore energy and calm
and renew interest in engagement
Sleep preparation Engaging in routines that prepare the self for a comfortable rest,
such as grooming and undressing, reading or listening to
music, saying goodnight to others, and engaging in meditation
or prayers; determining the time of day and length of time
(Continued)
GUIDELINES
desired for sleeping and the time needed to wake; establishing
sleep patterns that support growth and health (patterns are often
personally and culturally determined); preparing the physical
environment for periods of sleep, such as making the bed or
space on which to sleep, ensuring warmth or coolness and
protection, setting an alarm clock, securing the home (e.g., by
locking doors or closing windows or curtains), setting up sleep-

supporting equipment (e.g., CPAP machine), and turning off
electronics and lights
Sleep participation Taking care of personal needs for sleep, such as ceasing ac-
tivities to ensure onset of sleep, napping, and dreaming; sus-
taining a sleep state without disruption; meeting nighttime
toileting and hydration needs, including negotiating the needs of
and interacting with others (e.g., children, partner) within the
social environment, such as providing nighttime caregiving
(e.g., breastfeeding) and monitoring comfort and safety of
others who are sleeping
Education—Activities needed for learning and participating in the educational environment.
Formal educational participation Participating in academic (e.g., math, reading, degree course-
work), nonacademic (e.g., recess, lunchroom, hallway),
extracurricular (e.g., sports, band, cheerleading, dances),
technological (e.g., online assignment completion, distance
learning), and vocational (including prevocational) educational
activities
Informal personal educational needs or interests exploration Identifying topics and methods for obtaining topic-related in-
(beyond formal education) formation or skills
Informal educational participation Participating in classes, programs, and activities that provide
instruction or training outside of a structured curriculum in
identified areas of interest
Work—Labor or exertion related to the development, production, delivery, or management of objects or services; benefits
may be financial or nonfinancial (e.g., social connectedness, contributions to society, structure and routine to daily life;
Christiansen & Townsend, 2010; Dorsey et al., 2019).
Employment interests and pursuits Identifying and selecting work opportunities consistent with
personal assets, limitations, goals, and interests (adapted from
Mosey, 1996, p. 342)
Employment seeking and acquisition Advocating for oneself; completing, submitting, and reviewing
application materials; preparing for interviews; participating in
interviews and following up afterward; discussing job benefits;
finalizing negotiations
Job performance and maintenance Creating, producing, and distributing products and services;
maintaining required work skills and patterns; managing time
use; managing relationships with coworkers, managers, and
customers; following and providing leadership and supervision;
initiating, sustaining, and completing work; complying with
work norms and procedures; seeking and responding to
feedback on performance
(Continued)
GUIDELINES
Retirement preparation and adjustment Determining aptitudes, developing interests and skills, selecting
vocational pursuits, securing required resources, adjusting
lifestyle in the absence of the worker role
Volunteer exploration Identifying and learning about community causes, organiza-
tions, and opportunities for unpaid work consistent with per-
sonal skills, interests, location, and time available

Volunteer participation Performing unpaid work activities for the benefit of selected
people, causes, or organizations
Play—Activities that are intrinsically motivated, internally controlled, and freely chosen and that may include suspension of
reality (e.g., fantasy; Skard & Bundy, 2008), exploration, humor, risk taking, contests, and celebrations (Eberle, 2014; Sutton-Smith,
2009). Play is a complex and multidimensional phenomenon that is shaped by sociocultural factors (Lynch et al., 2016).
Play exploration Identifying play activities, including exploration play, practice
play, pretend play, games with rules, constructive play, and
symbolic play (adapted from Bergen, 1988, pp. 64–65)
Play participation Participating in play; maintaining a balance of play with other
occupations; obtaining, using, and maintaining toys, equip-
ment, and supplies
Leisure—“Nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time not
committed to obligatory occupations such as work, self-care, or sleep” (Parham & Fazio, 1997, p. 250).
Leisure exploration Identifying interests, skills, opportunities, and leisure activities
Leisure participation Planning and participating in leisure activities; maintaining a
balance of leisure activities with other occupations; obtaining,
using, and maintaining equipment and supplies
Social Participation—Activities that involve social interaction with others, including family, friends, peers, and community
members, and that support social interdependence (Bedell, 2012; Khetani & Coster, 2019; Magasi & Hammel, 2004).
Community participation Engaging in activities that result in successful interaction at the
community level (e.g., neighborhood, organization, workplace,
school, digital social network, religious or spiritual group)
Family participation Engaging in activities that result in “interaction in specific re-
quired and/or desired familial roles” (Mosey, 1996, p. 340)
Friendships Engaging in activities that support “a relationship between two
people based on mutual liking in which partners provide support
to each other in times of need" (Hall, 2017, para. 2)
Intimate partner relationships Engaging in activities to initiate and maintain a close relation-
ship, including giving and receiving affection and interacting in
desired roles; intimate partners may or may not engage in sexual
activity
Peer group participation Engaging in activities with others who have similar interests,
age, background, or social status
Note. CPAP = continuous positive airway pressure.
GUIDELINES
Table 3. Examples of Occupations for Persons, Groups, and Populations

Persons engage in occupations, and groups engage in shared occupations; populations as a whole do not engage in shared
occupations, which happen at the person or group level. Occupational therapy practitioners provide interventions for persons, groups,
and populations.
Occupation Category Client Type Example
Activities of daily living Person Older adult completing bathing with assistance
from an adult child
Group Students eating lunch during a lunch break
Instrumental activities of daily living Person Parent using a phone app to pay a babysitter

electronically
Group Club members using public transportation to
arrive at a musical performance
Health management Person Patient scheduling an appointment with a spe-
cialist after referral by the primary care doctor
Group Parent association sharing preparation of healthy
foods to serve at a school-sponsored festival
Rest and sleep Person Person turning off lights and adjusting the room
temperature to 68° before sleep
Group Children engaging in nap time at a day care center
Education Person College student taking an African-American his-
tory class online
Group Students working on a collaborative science
project on robotics
Work Person Electrician turning off power before working on a
power line
Group Peers volunteering for a day of action at an animal
shelter
Play Person Child playing superhero dress up
Group Class playing freeze tag during recess
Leisure Person Family member knitting a sweater for a new baby
Group Friends meeting for a craft circle
Social participation Person New mother going to lunch with friends
Group Older adults gathering at a community center to
wrap holiday presents for charity distribution
GUIDELINES
Table 4. Context: Environmental Factors

Context is the broad construct that encompasses environmental factors and personal factors. Environmental factors are aspects of the
physical, social, and attitudinal surroundings in which people live and conduct their lives.
Environmental Factor Components Examples
Natural environment and human-made Physical geography • Raised flower beds in a backyard
changes to the environment: Animate and • Local stream cleanup by Boy Scouts
inanimate elements of the natural or during a community service day project
physical environment and components of • Highway expansion cutting through an
that environment that have been modified established neighborhood
by people, as well as characteristics of

Population: Groups of people living in a • Universal access playground where
human populations within the given environment who share the same children with mobility impairment can
environment pattern of environmental adaptation play
• Hearing loop installed in a synagogue
for congregation members with hearing
aids
• Tree-shaded, solid-surface walking path
enjoyed by older adults in a senior living
community
Flora (plants) and fauna (animals) • Nonshedding service dog
• Family-owned herd of cattle
• Community garden
Climate: Meteorological features and • Sunny day requiring use of sunglasses
events, such as weather • Rain shower prompting a crew of road
workers to don rain gear
• Unusually high temperatures turning a
community ice skating pond to slush
Natural events: Regular or irregular geo- • Barometric pressure causing a
graphic and atmospheric changes that headache
cause disruption in the physical • Flood of a local creek damaging
environment neighborhood homes
• Hurricane devastating a low-lying
region
Human-caused events: Alterations or dis- • High air pollution forcing a person with
turbances in the natural environment lung disease to stay indoors
caused by humans that result in the dis- • Accessible dock at a local river park
ruption of day-to-day life demolished to make way for a new
bridge construction project
• Derailment of a train loaded with highly
combustible chemicals leading to the
emergency total evacuation of a small
town
Light: Light intensity and quality • Darkness requiring use of a reading lamp
• Office with ample natural light
• Street lamps
Time-related changes: Natural, regularly • Jet lag
occurring, or predictable change; rhythm • Quitting time at the end of a work shift
and duration of activity; time of day, week, • Summer solstice
month, season, or year; day–night cycles;
lunar cycles
(Continued)
GUIDELINES
Table 4. Context: Environmental Factors (cont’d)

Sound and vibration: Heard or felt phe- • Vibration of a cell phone indicating a
nomena that may provide useful or dis- text message
tracting information about the world • Bell signaling the start of the school day
• Outdoor emergency warning system on
a college campus
Air quality: Characteristics of the atmo- • Heavy perfume use by a family member
sphere (outside buildings) or enclosed causing an asthmatic reaction

areas of air (inside buildings) • Smoking area outside an office building
• High incidence of respiratory diseases
near an industrial district
Products and technology: Natural or Food, drugs, and other products or sub- • Preferred snack
human-made products or systems of stances for personal consumption • Injectable hormones for a transgender
products, equipment, and technology that man
are gathered, created, produced, or • Grade-school cafeteria lunch
manufactured General products and technology for • Toothbrush
personal use in daily living (including • Household refrigerator
assistive technology and products) • Shower in a fitness or exercise facility
Personal indoor and outdoor mobility and • Four-wheeled walker
transportation equipment used by people • Family car
in activities requiring movement inside and • Elevator in a multistory apartment
outside of buildings building
Communication: Activities involving • Hearing aid
sending and receiving information • Text chain via personal cell phones
• Use of emergency response system to
warn region of impending dangerous
storms
Education: Processes and methods for • Textbook
acquiring knowledge, expertise, or skill • Online course
• Curriculum for workplace sexual ha-
rassment program
Employment: Paid work activities • Home office for remote work
• Assembly factory
• Internet connection for health care workers
to access electronic medical records
Cultural, recreational, and sporting • Gaming console
activities • Instruments for a university marching
band
• Soccer stadium
Practice of religion and spirituality • Prayer rug
• Temple
• Sunday church service television
broadcast
Indoor and outdoor human-made envi- • Home bathroom with grab bars and
ronments that are planned, designed, and raised toilet seat
constructed for public and private use • Accessible playground at a city park
• Zero-grade entry to a shopping mall
(Continued)
GUIDELINES

Assets for economic exchange, such as • Pocket change
money, goods, property, and other valu- • Household budget
ables that an individual owns or has rights • Condominium association tax bill
to use
Virtual environments occurring in simu- • Personal cell phone
lated, real-time, and near-time situations, • Synchronous video meeting of co-
absent of physical contact workers in distant locations

• Open-source video gaming community
Support and relationships: People or ani- Immediate and extended family • Spouses, partners, parents, siblings,
mals that provide practical physical or foster parents, and adoptive
emotional support, nurturing, protection, grandparents
assistance, and relationships to other • Biological families and found or con-
persons in the home, workplace, or school structed families
or at play or in other aspects of their daily Friends, acquaintances, peers, colleagues, • Trusted best friend
activities neighbors, and community members • Coworkers
• Helpful next-door neighbor
• Substance abuse recovery support
group sponsor
People in positions of authority and those • Teacher who offers extra tutoring
in subordinate positions • Legal guardian for a parentless minor
• Female religious reporting to a sister
superior
• New employee being oriented to the job
tasks by an assigned mentor
Personal care providers and personal as- Health care professionals and other
sistants providing support to individuals professionals serving a community
Domesticated animals • Therapy dog program in a senior living
community
• Horse kept to draw a buggy for an
Amish family’s transportation
Attitudes: Observable evidence of cus- Individual attitudes of immediate and ex- • Shared grief over the untimely death of
toms, practices, ideologies, values, norms, tended family, friends and acquaintances, a sibling
factual beliefs, and religious beliefs held by peers and colleagues, neighbors and • Automatic trust from a patient who
people other than the client community members, people in positions knows one’s father
of authority and subordinate positions, • Reliance among members of a faith
personal care providers and personal as- community
sistants, strangers, and health care and
other professionals
Societal attitudes, including discriminatory • Failure to acknowledge a young person
practices who wants to vote for the first time
• Racial discrimination in job hiring
processes
Social norms, practices, and ideologies No time off work allowed to observe a
that marginalize specific populations religion’s holy day
Services, systems, and policies: Benefits, Services designed to meet the needs of • Economic services, including Social
structured programs, and regulations for persons, groups, and populations Security income and public assistance
operations, provided by institutions in
(Continued)
GUIDELINES

various sectors of society, designed to • Health services for preventing and
meet the needs of persons, groups, and treating health problems, providing
populations medical rehabilitation, and promoting
healthy lifestyles
Systems established by governments at • Public utilities (e.g., water, electricity,
the local, regional, national, and interna- sanitation)
tional levels or by other recognized • Communications (transmission and

authorities exchange of information)
• Transportation systems
• Political systems related to voting,
elections, and governance
Policies constituted by rules, regulations, • Architecture, construction, open space
conventions, and standards established by use, and housing policies
governments at the local, regional, na- • Civil protection and legal services
tional, and international levels or by other • Labor and employment policies related
recognized authorities to finding suitable work, looking for
different work, or seeking promotion
GUIDELINES
Table 5. Context: Personal Factors

Context is the broad construct that encompasses environmental factors and personal factors. Personal factors are the particular
background of a person’s life and living and consist of the unique features of the person that are not part of a health condition or health
state.
Personal Factor Person A Person B
Age (chronological) • 48 years old • 14 years old
Sexual orientation • Attracted to men • Attracted to all genders
Gender identity • Female • Male

Race and ethnicity • Black French Caribbean • Southeast Asian Hmong
Cultural identification and cultural attitudes • Urban Black • Traditional clan structure
• Feminist • Elders who are decision makers for
• Caribbean island identification community
Social background, social status, and so- • Urban, upscale neighborhood • Family owns small home
cioeconomic status • Friends in the professional workforce • Father with a stable job in light
• Income that allows for luxury manufacturing
• Mother who is a child care provider for
neighborhood children
Upbringing and life experiences • No siblings • Traditional
• Raised in household with grandmother • Born in a refugee camp before parents
as caregiver emigrated
• Moved from California to Boston while an • Youngest of five siblings
adolescent • Lives in a small city in the Upper
Midwest
Habits and past and current behavioral • Coffee before anything else • Organized and attentive to family
patterns • Meticulous about dress • Never misses a family meal
Individual psychological assets, including • Anxious when not working • Known for being calm
temperament, character traits, and coping • Extroverted • Not outgoing but friendly to all
styles, for handling responsibilities, stress, • High level of confidence • Does not speak up or complain at
crises, and other psychological demands • Readily adapts approach to and inter- school during conflict
(e.g., extroversion, agreeableness, con- actions with those who are culturally
scientiousness, psychic stability, open- different
ness to experience, optimism, confidence)
Education • Master’s degree in political science • High school freshman
• Law degree • Advanced skills in the sciences
Profession and professional identity • Public interest lawyer • Public high school student
Lifestyle • High-rise apartment • Engaged in clan and community
• Likes urban nightlife and casual dating • Four older siblings who live nearby
• Works long hours
Other health conditions and fitness • Treated for anorexia nervosa while an • Wears eyeglasses for astigmatism
adolescent • Sedentary at home except for assigned
• Occasional runner chores
GUIDELINES
Table 6. Performance Patterns

Performance patterns are the habits, routines, roles, and rituals that may be associated with different lifestyles and used in the process
of engaging in occupations or activities. These patterns are influenced by context and time use and can support or hinder occupational
performance.
Category Description Examples
Person
Habits “Specific, automatic behaviors performed repeat- • Automatically puts car keys in the same place
edly, relatively automatically, and with little varia- • Spontaneously looks both ways before crossing
tion” (Matuska & Barrett, 2019, p. 214). Habits can the street

be healthy or unhealthy, efficient or inefficient, and • Always turns off the stove burner before re-
supportive or harmful (Dunn, 2000). moving a cooking pot
• Activates the alarm system before leaving the
home
• Always checks smartphone for emails or text
messages on waking
• Snacks when watching television
Routines Patterns of behavior that are observable, regular, • Follows a morning sequence to complete toi-
and repetitive and that provide structure for daily leting, bathing, hygiene, and dressing
life. They can be satisfying, promoting, or dam- • Follows the sequence of steps involved in meal
aging. Routines require delimited time commit- preparation
ment and are embedded in cultural and ecological • Manages morning routine to drop children off at
contexts (Fiese, 2007; Segal, 2004). school and arrive at work on time
Roles Aspects of identity shaped by culture and context • Sibling in a family with three children
that may be further conceptualized and defined by • Retired military personnel
the client and the activities and occupations one • Volunteer at a local park district
engages in. • Mother of an adolescent with developmental
disabilities
• Student with a learning disability studying
computer technology
• Corporate executive returning to part-time work
after a stroke
Rituals Symbolic actions with spiritual, cultural, or social • Shares a highlight from the day during evening
meaning contributing to the client’s identity and meals with family
reinforcing values and beliefs. Rituals have a strong • Kisses a sacred book before opening the pages
affective component and consist of a collection of to read
events (Fiese, 2007; Fiese et al., 2002; Segal, • Recites the Pledge of Allegiance before the start
2004). of the school day
Group and Population
Routines Patterns of behavior that are observable, regular, Group
and repetitive and that provide structure for daily • Workers attending weekly staff meetings
life. They can be satisfying, promoting, or dam- • Students turning in homework assignments as
aging. Time provides an organizational structure or they enter the classroom
rhythm for routines (Larson & Zemke, 2003). • Exercise class attendees setting up their mats
Routines are embedded in cultural and ecological and towels before class
contexts (Segal, 2004).
Population
• Parents of young children following health
practices such as yearly checkups and sched-
uled immunizations
(Continued)
GUIDELINES
Table 6. Performance Patterns (cont’d)

Category Description Examples
• Corporations following business practices such
as providing services for disadvantaged pop-
ulations (e.g., loans to underrepresented
groups)
• School districts following legislative procedures
such as those associated with the Individuals
With Disabilities Education Improvement Act of

2004 (Pub. L. 108-446) or Medicare
Roles Sets of behaviors by the group or population ex- Group
pected by society and shaped by culture and • Nonprofit civic group providing housing for
context that may be further conceptualized and people living with mental illness
defined by the group or population. • Humanitarian group distributing food and
clothing donations to refugees
• Student organization in a university educating
elementary school children about preventing
bullying
Population
• Parents providing care for children until they
become adults
• Grandparents or older community members
being consulted before decisions are made
Rituals Shared social actions with traditional, emotional, Group
purposive, and technological meaning contributing • Employees of a company attending an annual
to values and beliefs within the group or holiday celebration
population. • Members of a community agency hosting a
fundraiser every spring
Population
•Citizens of a country suspending work activities
in observance of a national holiday
GUIDELINES
Table 7. Performance Skills for Persons

Performance skills are observable, goal-directed actions that result in a client’s quality of performing desired occupations. Skills are
supported by the context in which the performance occurs, including environmental and client factors (Fisher & Marterella, 2019).
Effective use of motor and process performance skills is demonstrated when the client carries out an activity efficiently, safely, with
ease, or without assistance. Effective use of social interaction performance skills is demonstrated when the client completes
interactions in a manner that matches the demands of the social situation. Ineffective use of performance skills is demonstrated when
the client routinely requires assistance or support to perform activities or engage in social interactions.
The examples in this table are limited to descriptions of the client’s ability to use each performance skill in an effective or ineffective
manner. A client who demonstrates ineffective use of performance skills may be able to successfully complete the entire occupation
with the use of occupational or environmental adaptations. Successful occupational performance by the client may be achieved when

such adaptions are used.
Examples
Specific Skill Definitions Effective Performancea Ineffective Performanceb
Motor Skills—“Motor skills are the group of performance skills that represent small, observable actions related to moving
oneself or moving and interacting with tangible task objects (e.g., tools, utensils, clothing, food or other supplies, digital devices,
plant life) in the context of performing a personally and ecologically relevant daily life task” (Fisher & Marterella, 2019, p. 331).
Positioning the body Washing dishes at the kitchen sink
Stabilizes—Moves through task environ- Person moves through the kitchen without Person momentarily props on the counter
ment and interacts with task objects propping or loss of balance. to stabilize body while standing at the sink
without momentary propping or loss of and washing dishes.
balance
Aligns—Interacts with task objects with- Person washes dishes without using the Person persistently leans on the counter,
out evidence of persistent propping or counter for support. resulting in ineffective performance when
leaning washing dishes.
Positions—Positions self an effective Person places body or wheelchair at an Person positions body or wheelchair too
distance from task objects and without effective distance for washing dishes. far from the sink, resulting in difficulty
evidence of awkward arm or body reaching for dishes in the sink.
positions
Obtaining and holding objects Acquiring a game from a cabinet in preparation for a family activity
Reaches—Effectively extends arm and, Person reaches without effort for the game Person reaches with excessive physical
when appropriate, bends trunk to ef- box. effort for the game box.
fectively grasp or place task objects that
are out of reach
Bends—Flexes or rotates trunk as ap- Person bends without effort when reach- Person demonstrates excessive stiffness
propriate when sitting down or when ing for the game box. when bending to reach for the game box.
bending to grasp or place task objects
that are out of reach
Grips—Effectively pinches or grasps task Person grips the game box and game Person grips the game box ineffectively,
objects such that the objects do not slip pieces, and they do not slip from the hand. and the box slips from the hand so that
(e.g., from between fingers, from be- game pieces spill.
tween teeth, from between hand and
supporting surface)
Manipulates—Uses dexterous finger Person readily manipulates the game Person fumbles the game pieces so that
movements, without evidence of fum- pieces with fingers while setting up and some pieces fall off the game board.
bling, when manipulating task objects playing the game.
(Continued)
GUIDELINES
Table 7. Performance Skills for Persons (cont’d)

Examples
Performance Skills: Motor Skills (cont’d)
Moving self and objects Completing janitorial tasks at a factory site
Coordinates—Uses two or more body Person uses both hands to shuffle the Person uses both hands to shuffle the
parts together to manipulate and hold game cards without fumbling them, and cards but fumbles the deck, and the cards

task objects without evidence of fumbling the cards do not slip from the hands. slip out of the hands.
or task objects slipping from the grasp
Moves—Effectively pushes or pulls task Person moves the broom easily, pushing Person demonstrates excessive effort to
objects along a supporting surface, and pulling it across the floor. move the broom across the floor when
pulls to open or pushes to close doors sweeping.
and drawers, or pushes on wheels to
propel a wheelchair
Lifts—Effectively raises or lifts task objects Person easily lifts cleaning supplies out of Person needs to use both hands to lift
without evidence of excessive physical the cart. small lightweight containers of cleaning
effort supplies out of the cart.
Walks—During task performance, ambu- Person walks steadily through the factory. Person demonstrates unstable walking
lates on level surfaces without shuffling while performing janitorial duties or walks
feet, becoming unstable, propping, or while supporting self on the cart.
using assistive devices
Transports—Carries task objects from one Person carries cleaning supplies from one Person is unstable when transporting
place to another while walking or factory location to another, either by cleaning supplies throughout the factory.
moving in a wheelchair walking or using a wheelchair, without
effort.
Calibrates—Uses movements of appro- Person uses an appropriate amount of Person applies too little force to squeeze
priate force, speed, or extent when force to squeeze liquid soap onto a soap out of the container onto the
interacting with task objects (e.g., does cleaning cloth. cleaning cloth.
not crush task objects, pushes a door
with enough force to close it without a
bang)
Flows—Uses smooth and fluid arm and Person demonstrates fluid arm and wrist Person demonstrates stiff and jerky arm
wrist movements when interacting with movements when wiping tables. and wrist movements when wiping
task objects tables.
Sustaining performance Bathing an older parent as caregiver
Endures—Persists and completes the task Person completes bathing of parent Person stops to rest, interrupting the task
without demonstrating physical fatigue, without evidence of physical fatigue. of bathing the parent.
pausing to rest, or stopping to catch
breath
Paces—Maintains a consistent and ef- Person uses an appropriate tempo when Person sometimes rushes or delays ac-
fective rate or tempo of performance bathing the parent. tions when bathing the parent.
throughout the entire task performance
Process Skills—“Process skills are the group of performance skills that represent small, observable actions related to selecting,
interacting with, and using tangible task objects (e.g., tools, utensils, clothing, food or other supplies, digital devices, plant life);
carrying out individual actions and steps; and preventing problems of occupational performance from occurring or reoccurring in
the context of performing a personally and ecologically relevant daily life task” (Fisher & Marterella, 2019, pp. 336–337).
(Continued)
GUIDELINES

Examples
Performance Skills: Process Skills (cont’d)
Sustaining performance Writing sentences for a school assignment
Paces—Maintains a consistent and ef- Person uses a consistent and even tempo Person rushes writing sentences,
fective rate or tempo of performance when writing sentences. resulting in incorrectly formed letters or

throughout the entire task performance misspelled words.
Attends—Does not look away from task Person maintains gaze on the assignment Person looks toward another student and
performance, maintaining the ongoing and continues writing sentences without pauses when writing sentences.
task progression pause.
Heeds—Carries out and completes the Person completes the assignment, writing Person writes fewer sentences than re-
task originally agreed on or specified by the number of sentences required. quired, not completing the assignment.
another person
Applying knowledge Taking prescribed medications
Chooses—Selects necessary and appro- Person chooses specified medicine bottles Person chooses an incorrect medicine
priate type and number of objects for appropriate for the specific timed dose. bottle for the specific timed dose.
the task, including the task objects that
one chooses or is directed to use (e.g.,
by a teacher)
Uses—Applies task objects as they are Person uses a medicine spoon to take a Person uses a tablespoon to take a 1-
intended (e.g., using a pencil sharpener dose of liquid medicine. teaspoon dose of liquid medicine.
to sharpen a pencil but not a crayon)
and in a hygienic fashion
Handles—Supports or stabilizes task ob- Person supports the medicine bottle, Person allows the medicine bottle to tip,
jects appropriately, protecting them keeping it upright without the bottle tip- and pills spill from the bottle.
from being damaged, slipping, moving, ping or falling.
or falling
Inquires—(1) Seeks needed verbal or Person reads the label on the Person asks the care provider what dose
written information by asking questions medicine bottle before taking the to take having already read the dose on
or reading directions or labels and (2) medication. the label.
does not ask for information when fully
oriented to the task and environment
and recently aware of the answer
Organizing timing Using an ATM to get cash to pay a babysitter
Initiates—Starts or begins the next task Person begins each step of ATM use Person pauses before entering the PIN
action or task step without any without hesitation. into the ATM.
hesitation
Continues—Performs single actions or Person completes each step of ATM use Person starts to enter the PIN, pauses,
steps without any interruptions so that without delays. and then continues entering the PIN.
once an action or task step is initiated,
performance continues without pauses
or delays until the action or step is
completed
(Continued)
GUIDELINES

Examples
Sequences—Performs steps in an effec- Person completes each step of ATM use in Person attempts to enter the PIN before
tive or logical order and with an absence logical order. inserting the bank card into the card
of randomness in the ordering or in- reader.
appropriate repetition of steps

Terminates—Brings to completion single Person completes each step of ATM use in Person persists in entering numbers after
actions or single steps without inappro- the appropriate length of time. completing the four-digit PIN.
priate persistence or premature cessation
Organizing space and objects Managing clerical duties for a large company
Searches/locates—Looks for and locates Person readily locates needed office sup- Person searches a shelf a second time to
task objects in a logical manner plies from shelves and drawers. locate needed clerical supplies.
Gathers—Collects related task objects into Person gathers required clerical tools and Person places required paper and pen in
the same work space and regathers task supplies in the assigned work space. different work spaces and then must
objects that have spilled, fallen, or been move them to the same work space.
misplaced
Organizes—Logically positions or spatially Person organizes required clerical tools Person places books on top of papers,
arranges task objects in an orderly fashion and supplies within the work space so all resulting in a crowded work space.
within a single work space or between are within reach.
multiple appropriate work spaces such that
the work space is not too spread out or too
crowded
Restores—Puts away task objects in ap- Person returns clerical tools and supplies Person puts pens and extra paper in a
propriate places and ensures that the to their original storage location. different storage closet from where
immediate work space is restored to its originally found.
original condition
Navigates—Moves body or wheelchair Person moves through the office space Person bumps hand into the edge of the
without bumping into obstacles when without bumping into office furniture or desk when reaching for a pen from the
moving through the task environment machines. pen holder.
or interacting with task objects
Adapting performance Preparing a green salad for a family meal
Notices/responds—Responds appropri- Person notices the carrot rolling off the Person delays noticing a rolling carrot,
ately to (1) nonverbal task-related cues cutting board and catches it before it rolls and it rolls off the cutting board onto the
(e.g., heat, movement), (2) the spatial onto the floor. floor.
arrangement and alignment of task
objects to one another, and (3) cup-
board doors or drawers that have been
left open during task performance
Adjusts—Overcomes problems with on- Person readily adjusts the flow of water Person delays turning off the water tap
going task performance effectively by from the tap when washing vegetables. after washing the vegetables.
(1) going to a new workspace; (2)
moving task objects out of the current
workspace; or (3) adjusting knobs, di-
als, switches, or water taps
(Continued)
GUIDELINES

Examples
Accommodates—Prevents ineffective Person prevents problems from occurring Person does not prevent problems from
performance of all other motor and during the salad preparation. occurring, such as carrots rolling off the
process skills and asks for assistance cutting board and onto the floor.
only when appropriate or needed

Benefits—Prevents ineffective perfor- Person prevents problems from continu- Person retrieves the carrot from the floor
mance of all other motor and process ing or reoccurring during the salad and puts it back on the cutting board, and
skills from recurring or persisting preparation. the carrot rolls off the board again.
Social Interaction Skills—“Social interaction skills are the group of performance skills that represent small, observable actions
related to communicating and interacting with others in the context of engaging in a personally and ecologically relevant daily
life task performance that involves social interaction with others” (Fisher & Marterella, 2019, p. 342).
Initiating and terminating social interaction Participating in a community support group
Approaches/starts—Approaches or initi- Person politely begins interactions with Person begins interactions with support
ates interaction with the social partner support group members. group members by yelling at them from
in a manner that is socially appropriate across the room.
Concludes/disengages—Effectively termi- Person politely ends a conversation with a Person abruptly ends interaction with the
nates the conversation or social inter- support group member. support group by walking out of the
action, brings to closure the topic under room.
discussion, and disengages or says
goodbye
Producing social interaction Child playing in the sandbox with others to build roads for cars and trucks
Produces speech—Produces spoken, Person produces clear verbal, signed, or Person mumbles when interacting with
signed, or augmentative (i.e., com- augmentative messages to communicate other children playing in the sandbox, and
puter-generated) messages that are with other children playing in the sandbox. the other children do not understand the
audible and clearly articulated message.
Gesticulates—Uses socially appropriate Person gestures by waving or pointing Person uses aggressive gestures when
gestures to communicate or support a while communicating with other children interacting with other children playing in
message playing in the sandbox. the sandbox.
Speaks fluently—Speaks in a fluent and Person speaks, without pausing, stutter- Person hesitates or pauses when talking
continuous manner, with an even pace ing, or hesitating, when engaging with with other children playing in the
(not too fast, not too slow) and without other children playing in the sandbox. sandbox.
pauses or delays, while sending a
message
Older adult in a senior residence talking with other residents
Physically supporting social interaction during a shared mealtime
Turns toward—Actively positions or turns Person turns body and face toward other Person turns face away from other resi-
body and face toward the social partner residents while interacting during the dents while interacting during the meal.
or the person who is speaking meal.
Looks—Makes eye contact with the social Person makes eye contact with other Person looks down at own plate while
partner residents while interacting during the interacting during the meal.
meal.
(Continued)
GUIDELINES

Examples
Performance Skills: Social Interaction Skills (cont’d)
Places self—Positions self at an appro- Person sits an appropriate distance from Person sits too far from other residents,
priate distance from the social partner other residents at the table. interfering with interactions.
Touches—Responds to and uses touch or Person touches other residents appropri- Person reaches out, grasps another

bodily contact with the social partner in ately during the meal. resident’s shirt, and abruptly pulls on it
a socially appropriate manner during the meal.
Regulates—Does not demonstrate irrele- Person avoids demonstrating irrelevant, Person repeatedly taps the fork on the
vant, repetitive, or impulsive behaviors repetitive, or impulsive behaviors while plate while interacting during the meal.
during social interaction interacting during the meal.
Shaping content of social interaction Serving ice cream to customers in an ice cream shop
Questions—Requests relevant facts and Person asks customers for their choice of Person asks customers for their choice of
information and asks questions that ice cream flavor. ice cream flavor and then repeats the
support the intended purpose of the question after they respond.
social interaction
Replies—Keeps conversation going by Person readily replies with relevant an- Person delays in replying to customers’
replying appropriately to suggestions, swers to customers’ questions about ice questions or provides irrelevant
opinions, questions, and comments cream products. information.
Discloses—Reveals opinions, feelings, Person discloses no personal information Person reveals socially inappropriate
and private information about self or about self or others to customers. details about own family.
others in a socially appropriate manner
Expresses emotions—Displays affect and Person displays socially appropriate Person uses a sarcastic tone of voice
emotions in a socially appropriate emotions when sending messages to when describing ice cream flavor options.
manner customers.
Disagrees—Expresses differences of Person expresses a difference of opinion Person becomes argumentative when a
opinion in a socially appropriate manner about ice cream products in a polite way. customer requests a flavor that is not
available.
Thanks—Uses appropriate words and Person thanks the customers for pur- Person fails to say thank you after cus-
gestures to acknowledge receipt of chasing ice cream. tomers purchase ice cream.
services, gifts, or compliments
Sharing suggestions with others in a support group for persons experiencing
Maintaining flow of social interaction mental health challenges
Transitions—Handles transitions in the Person offers comments or suggestions Person abruptly changes the topic of
conversation or changes the topic that relate to the topic of mental health conversation to planning social activities
without disrupting the ongoing challenges, smoothly moving the topic in a during a discussion of mental health
conversation relevant direction. challenges.
Times response—Replies to social mes- Person replies to another group member’s Person replies to another group mem-
sages without delay or hesitation and question about community supports for ber’s question about community sup-
without interrupting the social partner mental health challenges after briefly ports for mental health challenges before
considering how best to respond. the other person finishes asking the
question.
(Continued)
GUIDELINES

Examples
Performance Skills: Social Interaction Skills (cont’d)
Times duration—Speaks for a reasonable Person sends messages about mental Person sends prolonged messages con-
length of time given the complexity of health challenges of an appropriate length. taining extraneous details.
the message
Takes turns—Speaks in turn and gives the Person engages in back-and-forth con- Person does not respond to comments
social partner the freedom to take their turn versation with others in the group. from others during the group discussion.

Verbally supporting social interaction Visiting a Social Security office to obtain information relative to potential benefits
Matches language—Uses a tone of voice, Person uses a tone of voice and vocabulary Person uses a loud voice and slang when
dialect, and level of language that are so- that match those of the Social Security interacting with the Social Security agent.
cially appropriate and matched to the social agent.
partner’s abilities and level of understanding
Clarifies—Responds to gestures or verbal Person rephrases the initial question when Person asks an unrelated question when
messages from the social partner sig- the Social Security agent requests the Social Security agent requests clari-
naling that the social partner does not clarification. fication of the initial question.
comprehend or understand a message
and ensures that the social partner is
following the conversation
Acknowledges and encourages— Person nods to indicate understanding of Person does not nod or use words to
Acknowledges receipt of messages, the information shared by the Social Se- acknowledge receipt of messages sent by
encourages the social partner to con- curity agent. the Social Security agent.
tinue the social interaction, and en-
courages all social partners to
participate in the interaction
Empathizes—Expresses a supportive at- Person shows empathy when the Social Person shows impatience when the So-
titude toward the social partner by Security agent expresses frustration with cial Security agent expresses frustration
agreeing with, empathizing with, or the slow computer system. with the slow computer system.
expressing understanding of the social
partner’s feelings and experiences
Adapting social interaction Deciding which restaurant to go to with a group of friends
Heeds—Uses goal-directed social inter- Person maintains focus on deciding which Person makes comments unrelated to
actions focused on carrying out and restaurant to go to. choosing a restaurant, disrupting the
completing the intended purpose of the group decision making.
social interaction
Accommodates—Prevents ineffective or Person avoids making ineffective re- Person asks a question that is irrelevant
socially inappropriate social interaction sponses to others about restaurant choice. to choosing a restaurant.
Benefits—Prevents problems with inef- Person avoids making reoccurring inef- Person persists in asking questions ir-
fective or socially inappropriate social fective comments during the decision relevant to choosing a restaurant.
interaction from recurring or persisting making.
Note. ATM = automated teller machine; PIN = personal identification number.
a
Effective use of motor and process performance skills is demonstrated when the client carries out an activity efficiently, safely, with ease, or without assistance. Effective use of
social interaction performance skills is demonstrated when the client completes interactions in a manner that matches the demands of the social situation. bIneffective
performance skills are demonstrated when the client routinely requires assistance or support to perform activities or engage in social interaction. Ineffective use of social
interaction performance skills is demonstrated when the client engages in social interactions in a manner that does not appropriately meet the demands of the social situation.
Source. From Powerful Practice: A Model for Authentic Occupational Therapy, by A. G. Fisher and A. Marterella, 2019, Fort Collins, CO: Center for Innovative OT
Solutions. Copyright © 2019 by the Center for Innovative OT Solutions. Adapted with permission.
GUIDELINES
Table 8. Performance Skills for Groups

To address performance skills for a group client, occupational therapy practitioners analyze the motor, process, and social interaction
skills of individual group members to identify whether ineffective performance skills may limit the group’s collective outcome.
Italicized words in the middle column are specific performance skills defined in Table 7.
Ineffective Performance by an Impact on Group Collective
Performance Skill Category Individual Group Member Outcome
Group collective outcome: Religious organization committee furnishing spaces for a preschool for member families
Motor—Obtaining and holding objects • Member reaches with excessive effort Other members may need to take re-
for chairs stored in closet. sponsibility for obtaining and holding

• Member bends with stiffness or exces- objects to accommodate the member’s
sive effort when reaching for the chairs. ineffective motor performance skills
• Member fumbles when gripping writing during the process of furnishing pre-
materials in preparation for recording school spaces.
committee decisions for planning.
• Member demonstrates limited finger
dexterity to manipulate tools for as-
sembling storage units for toys.
• Member is unable to coordinate one
hand and trunk to stabilize self while
gripping and loading toys onto shelves.
Process—Organizing space and objects • Member repeatedly asks for help when The group may need to accommodate the
searching for needed furniture or lo- member’s limitations in effectively orga-
cating play equipment that is organized nizing space and objects by adjusting the
logically in near and distant places within timing of the outcome to allow greater
the building. time to complete furnishing the preschool
• Member does not effectively gather re- spaces.
quired play activity materials in the
designated play spaces.
• Member has difficulty organizing toys or
play equipment within the various play
spaces in a logical and orderly fashion.
• Member does not restore toys or play
equipment to storage spaces to return the
preschool space to an effective order.
• Member bumps into play furniture when
navigating spaces to set up furniture to
meet the needs of families or groups.
Social interaction—Producing social • Member communicates in whispers The group decision-making process may
interaction when producing speech to communicate be hindered by the member’s difficulty in
with other members about decisions for producing social interactions. Limited
placing play equipment. communication during the tasks of
• Member delays in gesticulating so other placing furniture in preschool spaces may
members do not receive effective mes- cause confusion among group members.
sages while arranging toys and play
equipment.
• Member speaks fluently but too quickly
when communicating to friends, resulting
in challenges for other members in deci-
sion making for furnishing the preschool.
Source. Performance skill categories are from Powerful Practice: A Model for Authentic Occupational Therapy, by A. G. Fisher and A. Marterella, 2019, Fort Collins,
CO: Center for Innovative OT Solutions. Copyright © 2019 by the Center for Innovative OT Solutions. Adapted with permission.
GUIDELINES
Table 9. Client Factors

Client factors include (1) values, beliefs, and spirituality; (2) body functions; and (3) body structures. Client factors reside within the
client and influence the client’s performance in occupations.
Category Examples Relevant to Occupational Therapy Practice
Values, Beliefs, and Spirituality—Client’s (person’s, group’s, or population’s) perceptions, motivations, and related meaning
that influence or are influenced by engagement in occupations.
Values—Acquired beliefs and commitments, derived from Person
culture, about what is good, right, and important to do • Honesty with self and others
(Kielhofner, 2008) • Commitment to family

Group
• Obligation to provide a service
• Fairness
• Inclusion
Population
• Freedom of speech
• Equal opportunities for all
• Tolerance toward others
Beliefs—“Something that is accepted, considered to be true, or Person

held as an opinion” (“Belief,” 2020). • One is powerless to influence others.
• Hard work pays off.
Group
• Teaching others how to garden decreases their reliance on
grocery stores.
• Writing letters as part of a neighborhood group can support the
creation of a community park.
Population
•Some personal rights are worth fighting for.
•A new health care policy, as yet untried, will positively affect
society.
Spirituality—“A deep experience of meaning brought about by Person
engaging in occupations that involve the enacting of personal • Personal search for purpose and meaning in life
values and beliefs, reflection, and intention within a supportive • Guidance of actions by a sense of value beyond the acquisition
contextual environment” (Billock, 2005, p. 887). It is important of wealth or fame
to recognize spirituality “as dynamic and often evolving”
(Humbert, 2016, p. 12). Group
• Study of religious texts together
• Attendance at a religious service
Population
• Common search for purpose and meaning in life
• Guidance of actions by values agreed on by the collective
Body Functions—“The physiological functions of body systems (including psychological functions)” (WHO, 2001, p. 10).
This section of the table is organized according to the classifications of the ICF; for fuller descriptions and definitions, refer to
WHO (2001). This list is not all inclusive.
(Continued)
GUIDELINES
Table 9. Client Factors (cont’d)

Body Functions (cont'd)
Mental functions
Specific mental functions
Higher level cognitive Judgment, concept formation, metacognition, executive func-
tions, praxis, cognitive flexibility, insight
Attention Sustained shifting and divided attention, concentration,
distractibility

Memory Short-term, long-term, and working memory
Perception Discrimination of sensations (e.g., auditory, tactile, visual, ol-
factory, gustatory, vestibular, proprioceptive)
Thought Control and content of thought, awareness of reality vs. delu-
sions, logical and coherent thought
Mental functions of sequencing complex movement Mental functions that regulate the speed, response, quality, and
time of motor production, such as restlessness, toe tapping, or
hand wringing, in response to inner tension
Emotional Regulation and range of emotions; appropriateness of emotions,
including anger, love, tension, and anxiety; lability of emotions
Experience of self and time Awareness of one’s identity (including gender identity), body, and
position in the reality of one’s environment and of time
Global mental functions
Consciousness State of awareness and alertness, including the clarity and
continuity of the wakeful state
Orientation Orientation to person, place, time, self, and others
Psychosocial General mental functions, as they develop over the life span,
required to understand and constructively integrate the mental
functions that lead to the formation of the personal and inter-
personal skills needed to establish reciprocal social interactions,
in terms of both meaning and purpose
Temperament and personality Extroversion, introversion, agreeableness, conscientiousness,
emotional stability, openness to experience, self-control, self-
expression, confidence, motivation, impulse control, appetite
Energy Energy level, motivation, appetite, craving, impulse
Sleep Physiological process, quality of sleep
Sensory functions
Visual functions Quality of vision, visual acuity, visual stability, and visual field
functions to promote visual awareness of environment at var-
ious distances for functioning
Hearing functions Sound detection and discrimination; awareness of location and
distance of sounds
Vestibular functions Sensation related to position, balance, and secure movement
against gravity
Taste functions Association of taste qualities of bitterness, sweetness, sourness,
and saltiness
Smell functions Sensing of odors and smells
Proprioceptive functions Awareness of body position and space
(Continued)
GUIDELINES

Body Functions (cont'd)
Touch functions Feeling of being touched by others or touching various textures,
such as those of food; presence of numbness, paresthesia,
hyperesthesia
Interoception Internal detection of changes in one’s internal organs through
specific sensory receptors (e.g., awareness of hunger, thirst,
digestion, state of alertness)

Pain Unpleasant feeling indicating potential or actual damage to some
body structure; sensations of generalized or localized pain (e.g.,
diffuse, dull, sharp, phantom)
Sensitivity to temperature and pressure Thermal awareness (hot and cold), sense of force applied to skin
(thermoreception)
Neuromusculoskeletal and movement-related functions
Functions of joints and bones
Joint mobility Joint range of motion
Joint stability Maintenance of structural integrity of joints throughout the
body; physiological stability of joints related to structural
integrity
Muscle functions
Muscle power Strength
Muscle tone Degree of muscle tension (e.g., flaccidity, spasticity, fluctuation)
Muscle endurance Sustainability of muscle contraction
Movement functions
Motor reflexes Involuntary contraction of muscles automatically induced by
specific stimuli (e.g., stretch, asymmetrical tonic neck, sym-
metrical tonic neck)
Involuntary movement reactions Postural reactions, body adjustment reactions, supporting
reactions
Control of voluntary movement Eye–hand and eye–foot coordination, bilateral integration,
crossing of the midline, fine and gross motor control, oculo-
motor function (e.g., saccades, pursuits, accommodation,
binocularity)
Gait patterns Gait and mobility in relation to engagement in daily life activities
(e.g., walking patterns and impairments, asymmetric gait, stiff
gait)
Cardiovascular, hematological, immune, and respiratory system functions
(Note. Occupational therapy practitioners have knowledge of these body functions and understand broadly the interaction that
occurs among these functions to support health, well-being, and participation in life through engagement in occupation.)
Cardiovascular system functions Maintenance of blood pressure functions (hypertension, hy-
potension, postural hypotension), heart rate and rhythm
Hematological and immune system functions Protection against foreign substances, including infection, al-
lergic reactions
Respiratory system functions Rate, rhythm, and depth of respiration
Additional functions and sensations of the cardiovascular and Physical endurance, aerobic capacity, stamina, fatigability
respiratory systems
(Continued)
GUIDELINES

Voice and speech functions; digestive, metabolic, and endocrine system functions; genitourinary and reproductive
functions (Note. Occupational therapy practitioners have knowledge of these body functions and understand broadly the
interaction that occurs among these functions to support health, well-being, and participation in life through engagement in
occupation.)
Voice and speech functions Fluency and rhythm, alternative vocalization functions
Digestive, metabolic, and endocrine system functions Digestive system functions, metabolic system, and endocrine
system functions

Genitourinary and reproductive functions Genitourinary and reproductive functions
Skin and related structure functions (Note. Occupational therapy practitioners have knowledge of these body functions and
understand broadly the interaction that occurs among these functions to support health, well-being, and participation in life through
engagement in occupation.)
Skin functions Protection (presence or absence of wounds, cuts, or abrasions),
Hair and nail functions repair (wound healing)
Body Structures—“Anatomical parts of the body, such as organs, limbs, and their components” that support body function
(WHO, 2001, p. 10). This section of the table is organized according to the ICF classifications; for fuller descriptions and
definitions, refer to WHO (2001).
Structure of the nervous system Occupational therapy practitioners have knowledge of body
Structures related to the eyes and ears structures and understand broadly the interaction that occurs
Structures involved in voice and speech between these structures to support health, well-being, and
Structures of the cardiovascular, immunological, and respiratory participation in life through engagement in occupation.
systems
Structures related to the digestive, metabolic, and endocrine
systems
Structures related to the genitourinary and reproductive
systems
Structures related to movement
Note. The categorization of body functions and body structures is based on the ICF (WHO, 2001). The classification was selected because it has received wide
exposure and presents a language that is understood by external audiences. ICF = International Classification of Function, Disability and Health; WHO = World Health
Organization.
GUIDELINES
Table 10. Occupational Therapy Process for Persons, Groups, and Populations
The occupational therapy process applies to work with persons, groups, and populations. The process for groups and populations
mirrors that for persons. The process for populations includes public health approaches, and the process for groups may include both
person and population methods to address occupational performance (Scaffa & Reitz, 2014).
Process Process Step

Component Person Group Population
Evaluation Consultation and screening: Consultation and screening, envi- Environmental scan, trend analysis,
• Review client history ronmental scan: preplanning:
• Consult with interprofessional team • Identify collective need on the basis • Collect data to inform design of

• Administer standardized screening of available data intervention program by identify-
tools • For each individual in the group, ing information needs
+ Review history • Identify health trends in targeted
+ Administer standardized population and potential positive
screening tools and negative impacts on occupa-
+ Consult with interprofessional tional performance
team
Occupational profile: Occupational profile or community Needs assessment, community
•Interview client and caregiver profile: profile:
• Interview persons who make up the • Engage with persons within the
group population to determine their in-
• Engage with persons in the group to terests and needs and opportuni-
determine their interests, needs, and ties for collaboration
priorities • Identify priorities through
+ Surveys
+ Interviews
+ Group discussions or forums
Analysis of occupational Analysis of occupational Needs assessment, review of sec-
performance: performance: ondary data:
• Assess occupational performance • Conduct occupational and activity • Evaluate existing quantitative data,
• Conduct occupational and activity analysis which may include
analysis • Assess group context + Public health records
• Assess contexts • Assess the following for individual + Prevalence of disease or
• Assess performance skills and group members: disability
patterns + Occupational performance + Demographic data
• Assess client factors + Performance skills and patterns + Economic data
+ Client factors
• Analyze impact of individual per-
formance on the group
Synthesis of evaluation process: Synthesis of evaluation process: Data analysis and interpretation:
•Review and consolidate information • Review and consolidate information • Review and consolidate informa-
to select occupational outcomes to select collective occupational tion to support need for the pro-
and determine impact of perfor- outcomes gram and identify any missing data
mance patterns and client factors on • Review and consolidate information
occupation regarding each member’s perfor-
mance and its impact on the group
and the group’s occupational per-
formance as a whole
Intervention Development of the intervention plan: Development of the intervention plan Program planning:
•Identify client goals or program: • Identify short-term program
•Identify intervention outcomes • Identify collective group goals objectives
•Select outcome measures • Identify long-term program goals
(Continued)
GUIDELINES
Table 10. Occupational Therapy Process for Persons, Groups, and Populations (cont’d)
Process Process Step

Component Person Group Population
• Select methods for service delivery, • Identify intervention outcomes for •Select outcome measures to be
including theoretical framework the group used in program evaluation
• Select outcome measures • Select strategies for service deliv-
• Select methods for service delivery, ery, including theoretical
including theoretical framework framework
Intervention implementation: Intervention or program Program implementation:

• Carry out occupational therapy in- implementation: • Carry out program or advocacy
tervention to address specific oc- • Carry out occupational therapy in- action to address identified occu-
cupations, contexts, and tervention or program to address pational needs
performance patterns and skills af- the group’s specific occupations,
fecting performance contexts, and performance patterns
and skills affecting group
performance
Intervention review: Intervention review or program Program evaluation:
• Reevaluate and review client’s reevaluation: • Gather information on program
sponse to intervention • Reevaluate and review individual implementation
• Review progress toward goals and members’ and the group’s response • Measure the impact of the program
outcomes to intervention • Evaluate efficiency of program
• Modify plan as needed • Review progress toward goals and • Evaluate achievement of deter-
outcomes mined objectives
• Modify plan as needed
• Evaluate efficiency of program
• Evaluate achievement of determined
objectives
Outcomes Outcomes: Outcomes: Outcomes:
• Use measures to assess progress • Use measures to assess progress • Use measures to assess progress
toward outcomes toward outcomes toward long-term program goals
• Identify change in occupational • Identify change in occupational • Identify change in occupational
participation performance of individual members performance of targeted
and the group as a whole population
Transition: Transition: Sustainability plan:
•Facilitate client’s move from one life • Facilitate group members’ move • Develop action plan to maintain
role or experience to another, such from one life role or experience to program
as another, such as • Identify sources of funding
+ Moving to a new level of care + Moving to a new level of care • Build community capacity and
+ Transitioning between providers + Transitioning between providers support relationships to continue
+ Moving into a new setting or + Moving into a new setting or program
program program
Discontinuation: Discontinuation: Dissemination plan:
• Discontinue care after short- and • Discontinue care after the group’s • Share results with participants,
long-term goals have been achieved short- and long-term goals have stakeholders, and community
or client chooses to no longer been achieved members
participate • Implement discharge plan to sup- • Implement sustainability plan
• Implement discharge plan to support performance after discontinu-
port performance after discontinuation of services
ation of services
GUIDELINES
Table 11. Occupation and Activity Demands

Occupation and activity demands are the components of occupations and activities that occupational therapy practitioners consider in
their professional and clinical reasoning process. Activity demands are what is typically required to carry out the activity regardless of
client and context. Occupation demands are what is required by the specific client (person, group, or population) to carry out an
occupation. Depending on the context and needs of the client, occupation and activity demands can act as barriers to or supports for
participation. Specific knowledge about activity demands assists practitioners in selecting occupations for therapeutic purposes.
Occupational Demands: Required

by the Client (Person, Group,
Activity Demands: Typically Required or Population) to Carry
Type of Demand to Carry Out the Activity Out the Occupation

Relevance and importance General meaning of the activity within the Meaning the client derives from the oc-
given culture cupation, which may be subjective and
personally constructed; symbolic, un-
conscious, and metaphorical; and aligned
with the client’s goals, values, beliefs, and
needs and perceived utility
Person: Person:
Knitting clothing items for personal use, Knitting as a way to practice mindfulness
for income from sale, or as a leisure strategies for coping with anxiety
activity
Group: Group:
Cooking to provide nutrition, fulfill a family Preparation of a holiday meal with family
role, or engage in a leisure activity to connect members to each other and to
their culture and traditions
Population: Population:
Presence of accessible restrooms in public Creation of new accessible and all-gender
spaces in compliance with federal law restrooms to symbolize a community’s
commitment to safety and inclusion of
members with disabilities and LGBTQ+
members
Objects used and their properties: Tools Person: Computer workstation that includes a computer, keyboard, mouse, desk,
(e.g., scissors, dishes, shoes, volleyball), and chair
supplies (e.g., paints, milk, lipstick), Group: Financial and transportation resources for a group of friends to attend a
equipment (e.g., workbench, stove, bas- concert
ketball hoop), and resources (e.g., money,
transportation) required in the process of Population: Tools, supplies, and equipment for flood relief efforts to ensure safety
carrying out the activity or occupation and of people with disabilities
their inherent properties (e.g., heavy,
rough, sharp, colorful, loud, bitter tasting)
Space demands: Physical environment Person: Desk arrangement in an elementary school classroom
requirements of the occupation or activity Group: Accessible meeting space to run a fall prevention workshop
(e.g., size, arrangement, surface, lighting,
temperature, noise, humidity, ventilation) Population: Noise, lighting, arrangement, and temperature controls for a sensory-
friendly museum
Social demands: Elements of the social Person: Rules of engagement for a child at recess
and attitudinal environments required for Group: Expectations of travelers in an airport (e.g., waiting in line, following cues
the occupation or activity from staff and others, asking questions when needed)
Population: Understanding of the social and political climate of the geographic region
(Continued)
GUIDELINES
Table 11. Occupation and Activity Demands (cont’d)
Occupational Demands: Required

by the Client (Person, Group,
Activity Demands: Typically Required or Population) to Carry
Type of Demand to Carry Out the Activity Out the Occupation
Sequencing and timing demands: Tem- Person: Preferred sequence and timing of a client’s morning routine to affirm social,
poral process required to carry out the cultural, and gender identity
activity or occupation (e.g., specific steps,
Group: Steps a class of students takes in preparation to start the school day
sequence of steps, timing requirements)

Population: Public train schedules
Required actions and performance skills: Person: Body movements required to drive a car
Actions and performance skills (motor, Group and population: See “Performance Skills” section for discussion related to
process, and social interaction) that are an groups and population
inherent part of the activity or occupation
Required body functions: “Physiological Person: Cognitive level required for a child to play a game
functions of body systems (including Group and population: See “Client Factors” section for discussion of required body
psychological functions)” (WHO, 2001, p. functions related to groups and populations
10) required to support the actions used to
perform the activity or occupation
Required body structures: “Anatomical Person: Presence of upper limbs to play catch
parts of the body such as organs, limbs, Group and population: See “Client Factors” section for discussion of required body
and their components” that support body structures related to groups and populations
functions (WHO, 2001, p. 10) and are
required to perform the activity or
occupation
Note. WHO = World Health Organization.
GUIDELINES
Table 12. Types of Occupational Therapy Interventions

Occupational therapy intervention types include occupations and activities, interventions to support occupations, education and
training, advocacy, group interventions, and virtual interventions. Occupational therapy interventions facilitate engagement in
occupation to enable persons, groups, and populations to achieve health, well-being, and participation in life. The examples provided
illustrate the types of interventions that clients engage in (denoted as “client”) and that occupational therapy practitioners provide
(denoted as “practitioner”) and are not intended to be all-inclusive.
Intervention Type Description Examples
Occupations and Activities—Occupations and activities selected as interventions for specific clients are designed to meet
therapeutic goals and address the underlying needs of the client’s mind, body, and spirit. To use occupations and activities
therapeutically, the practitioner considers activity demands and client factors in relation to the client’s therapeutic goals and

contexts.
Occupations Broad and specific daily life events that Person
are personalized and meaningful to the Client completes morning dressing and hy-
client giene using adaptive devices.
Group
Client plays a group game of tag on the
playground to improve social participation.
Population
Practitioner creates an app to improve access
for people with autism spectrum disorder
using metropolitan paratransit systems.
Activities Components of occupations that are Person
objective and separate from the client’s Client selects clothing and manipulates
engagement or contexts. Activities as clothing fasteners in advance of dressing.
interventions are selected and designed
to support the development of perfor- Group
mance skills and performance patterns Group members separate into two teams for a
to enhance occupational engagement. game of tag.
Population
Client establishes parent volunteer commit-
tees at their children’s school.
Interventions to Support Occupations—Methods and tasks that prepare the client for occupational performance are used as
part of a treatment session in preparation for or concurrently with occupations and activities or provided to a client as a
home-based engagement to support daily occupational performance.
PAMs and mechanical modalities Modalities, devices, and techniques to Person
prepare the client for occupational Practitioner administers PAMs to decrease
performance. Such approaches should pain, assist with wound healing or edema
be part of a broader plan and not used control, or prepare muscles for movement to
exclusively. enhance occupational performance.
Group
Practitioner develops a reference manual on
postmastectomy manual lymphatic drainage
techniques for implementation at an outpa-
tient facility.
(Continued)
GUIDELINES
Table 12. Types of Occupational Therapy Interventions (cont’d)

Orthotics and prosthetics Construction of devices to mobilize, Person
immobilize, or support body structures Practitioner fabricates and issues a wrist
to enhance participation in occupations orthosis to facilitate movement and enhance
participation in household activities.
Group
Group members participate in a basketball game

with veterans using prosthetics after amputation.
Assistive technology and environ- Assessment, selection, provision, and Person
mental modifications education and training in use of high- Practitioner recommends using a visual
and low-tech assistive technology; ap- support (e.g., social story) to guide behavior.
plication of universal design principles;
and recommendations for changes to Group
the environment or activity to support Practitioner uses a smart board with speaker
the client’s ability to engage in system during a social skills group session to
occupations improve participants’ attention.
Population
Practitioner recommends that a large health
care organization paint exits in their facilities
to resemble bookshelves to deter patients
with dementia from eloping.
Wheeled mobility Products and technologies that facilitate Person
a client’s ability to maneuver through Practitioner recommends, in conjunction with
space, including seating and position- the wheelchair team, a sip-and-puff switch to
ing; improve mobility to enhance par- allow the client to maneuver the power
ticipation in desired daily occupations; wheelchair independently and interface with an
and reduce risk for complications such environmental control unit in the home.
as skin breakdown or limb contractures
Group
Group of wheelchair users in the same town
host an educational peer support event.
Self-regulation Actions the client performs to target Person
specific client factors or performance Client participates in a fabricated sensory
skills. Intervention approaches may environment (e.g., through movement, tactile
address sensory processing to promote sensations, scents) to promote alertness
emotional stability in preparation for before engaging in a school-based activity.
social participation or work or leisure
activities or executive functioning to Group
support engagement in occupation and Practitioner instructs a classroom teacher to
meaningful activities. Such approaches implement mindfulness techniques, visual
involve active participation of the client imagery, and rhythmic breathing after recess
and sometimes use of materials to to enhance students’ success in classroom
simulate components of occupations. activities.
Population
Practitioner consults with businesses and
community sites to establish sensory-friendly
environments for people with sensory pro-
cessing deficits.
(Continued)
GUIDELINES

Education and Training
Education Imparting of knowledge and information Person
about occupation, health, well-being, Practitioner provides education regarding
and participation to enable the client to home and activity modifications to the spouse
acquire helpful behaviors, habits, and or family member of a person with dementia to
routines support maximum independence.

Group
Practitioner participates in a team care
planning meeting to educate the family and
team members on a patient’s condition and
level of function and establish a plan of care.
Population
Practitioner educates town officials about the
value of and strategies for constructing
walking and biking paths accessible to people
who use mobility devices.
Training Facilitation of the acquisition of concrete Person
skills for meeting specific goals in a real- Practitioner instructs the client in the use of
life, applied situation. In this case, skills coping skills such as deep breathing to ad-
refers to measurable components of dress anxiety symptoms before engaging in
function that enable mastery. Training is social interaction.
differentiated from education by its goal
of enhanced performance as opposed to Group
enhanced understanding, although Practitioner provides an in-service on ap-
these goals often go hand in hand plying new reimbursement and practice
(Collins & O’Brien, 2003). standards adopted by a facility.
Population
Practitioner develops a training program to
support practice guidelines addressing oc-
cupational deprivation and cultural compe-
tence for practitioners working with refugees.
Advocacy—Efforts directed toward promoting occupational justice and empowering clients to seek and obtain resources to
support health, well-being, and occupational participation.
Advocacy Advocacy efforts undertaken by the Person
practitioner Practitioner collaborates with a client to procure
reasonable accommodations at a work site.
Group
Practitioner collaborates with and educates
teachers in an elementary school about in-
clusive classroom design.
Population
Practitioner serves on the policy board of an
organization to procure supportive housing
accommodations for people with disabilities.
(Continued)
GUIDELINES

Self-advocacy Advocacy efforts undertaken by the Person
client with support by the practitioner Client requests reasonable accommodations,
such as audio textbooks, to support their
learning disability.
Group
Client participates in an employee meeting to
request and procure adjustable chairs to

improve comfort at computer workstations.
Population
Client participates on a student committee
partnering with school administration to
develop cyberbullying prevention programs
in their district.
Group Interventions—Use of distinct knowledge of the dynamics of group and social interaction and leadership techniques to
facilitate learning and skill acquisition across the lifespan. Groups are used as a method of service delivery.
Functional groups, activity groups, Groups used in health care settings, Person
task groups, social groups, and other within the community, or within orga- Client participates in a group for adults with
groups nizations that allow clients to explore traumatic brain injury focused on individual
and develop skills for participation, in- goals for reentering the community after
cluding basic social interaction skills inpatient treatment.
and tools for self-regulation, goal set-
ting, and positive choice making Group
Group of older adults participates in volunteer
days to maintain participation in the com-
munity through shared goals.
Population
Practitioner works with middle school
teachers in a district on approaches to ad-
dress issues of self-efficacy and self-esteem
as the basis for creating resiliency in children
at risk for being bullied.
Virtual Interventions—Use of simulated, real-time, and near-time technologies for service delivery absent of physical contact,
such as telehealth or mHealth.
Telehealth (telecommunication and Use of technology such as video con- Person
information technology) and mHealth ferencing, teleconferencing, or mobile Practitioner performs a telehealth therapy
(mobile telephone application telephone application technology to session with a client living in a rural area.
technology) plan, implement, and evaluate occupa-
tional therapy intervention, education, Group
and consultation Client participates in an initial online support
group session to establish group protocols,
procedures, and roles.
Population
Practitioner develops methods and standards
for mHealth in community occupational
therapy practice.
Note. mHealth = mobile health; PAMs = physical agent modalities.
GUIDELINES
Table 13. Approaches to Intervention

Approaches to intervention are specific strategies selected to direct the evaluation and intervention processes on the basis of the
client’s desired outcomes, evaluation data, and research evidence. Approaches inform the selection of practice models, frames of
references, and treatment theories.
Approach Description Examples
Create, promote (health promotion) An intervention approach that does not Person
assume a disability is present or that any Develop a fatigue management program
aspect would interfere with performance. for a client recently diagnosed with
This approach is designed to provide multiple sclerosis
enriched contextual and activity experi-

ences that will enhance performance for all Group
people in the natural contexts of life Create a resource list of developmentally
(adapted from Dunn et al., 1998, p. 534). appropriate toys to be distributed by staff
at a day care program
Population
Develop a falls prevention curriculum for
older adults for trainings at senior centers
and day centers
Establish, restore (remediation, Approach designed to change client vari- Person
restoration) ables to establish a skill or ability that has Restore a client’s upper extremity
not yet developed or to restore a skill or movement to enable transfer of dishes
ability that has been impaired (adapted from the dishwasher into the upper
from Dunn et al., 1998, p. 533) kitchen cabinets
Collaborate with a client to help establish

morning routines needed to arrive at
school or work on time
Group
Educate staff of a group home for clients
with serious mental illness to develop a
structured schedule, chunking tasks to
decrease residents’ risk of being over-
whelmed by the many responsibilities of
daily life roles
Population
Restore access ramps to a church en-
trance after a hurricane
Maintain Approach designed to provide supports Person
that will allow clients to preserve the Provide ongoing intervention for a client
performance capabilities that they have with amyotrophic lateral sclerosis to ad-
regained and that continue to meet their dress participation in desired occupations
occupational needs. The assumption is through provision of assistive technology
that without continued maintenance in-
tervention, performance would decrease Group
and occupational needs would not be met, Maintain environmental modifications at
thereby affecting health, well-being, and a group home for young adults with
quality of life. physical disabilities for continued safety
and engagement with housemates
(Continued)
GUIDELINES
Table 13. Approaches to Intervention (cont’d)
Approach Description Examples

Population
Maintain safe and independent access for
people with low vision by increasing
hallway lighting in a community center
Modify (compensation, adaptation) Approach directed at “finding ways to Person
revise the current context or activity de- Simplify task sequence to help a person
mands to support performance in the with cognitive impairments complete a

natural setting, [including] compensatory morning self-care routine
techniques . . . [such as] enhancing some
features to provide cues or reducing other Group
features to reduce distractibility” (Dunn Modify a college campus housing build-
et al., 1998, p. 533) ing to accommodate a group of students
with mobility impairments
Population
Consult with architects and builders to
design homes that will support aging in
place and use universal design principles
Prevent (disability prevention) Approach designed to address the needs Person
of clients with or without a disability who Aid in the prevention of illicit substance
are at risk for occupational performance use by introducing self-initiated routine
problems. This approach is designed to strategies that support drug-free behavior
prevent the occurrence or evolution of
barriers to performance in context. Inter- Group
ventions may be directed at client, context, Prevent social isolation of employees by
or activity variables (adapted from Dunn promoting participation in after-work
et al., 1998, p. 534). group activities
Population
Consult with a hotel chain to provide an
ergonomics educational program
designed to prevent back injuries in
housekeeping staff
GUIDELINES
Table 14. Outcomes

Outcomes are the end result of the occupational therapy process; they describe what clients can achieve through occupational therapy
intervention. Some outcomes are measurable and are used for intervention planning and review and discharge planning. These
outcomes reflect the attainment of treatment goals that relate to engagement in occupation. Other outcomes are experienced by clients
when they have realized the effects of engagement in occupation and are able to return to desired habits, routines, roles, and rituals.
Adaptation is embedded in all categories of outcomes. The examples listed specify how the broad outcome of health and participation in
life may be operationalized.
Outcome Category Description Examples
Occupational performance Act of doing and accomplishing a selected Person

action (performance skill), activity, or oc- A patient with hip precautions showers safely with
cupation (Fisher, 2009; Fisher & Griswold, modified independence using a tub transfer
2019; Kielhofner, 2008) that results from bench and a long-handled sponge.
the dynamic transaction among the client,
the context, and the activity. Improving or Group
enhancing skills and patterns in occupa- A group of older adults cooks a holiday meal
tional performance leads to engagement in during their stay in a skilled nursing facility with
occupations or activities (adapted in part minimal assistance from staff.
from Law et al., 1996, p. 16).
Population
A community welcomes children with spina bifida
in public settings after a news story featuring
occupational therapy practitioners.
Improvement Increased occupational performance Person
through adaptation when a performance A child with autism plays interactively with a peer.
limitation is present An older adult returns home from a skilled
nursing facility as desired.
Group
Back strain in nursing personnel decreases as a
result of an in-service education program on body
mechanics for job duties that require bending and
lifting.
Population
Accessible playground facilities for all children are
constructed in city parks.
Enhancement Development of performance skills and Person
performance patterns that augment exist- A teenage mother experiences increased confidence
ing performance of life occupations when a and competence in parenting as a result of struc-
performance limitation is not present tured social groups and child development classes.
Group
Membership in the local senior citizen center
increases as a result of expanded social wellness
and exercise programs.
School staff have increased ability to address and
manage school-age youth violence as a result of
conflict resolution training to address bullying.
Population
Older adults have increased opportunities to
participate in community activities through ride-
share programs.
(Continued)
GUIDELINES
Table 14. Outcomes (cont’d)

Prevention Education or health promotion efforts Person
designed to identify, reduce, or stop the A child with orthopedic impairments is provided
onset and reduce the incidence of un- with appropriate seating and a play area.
healthy conditions, risk factors, diseases,
or injuries. Occupational therapy promotes Group
a healthy lifestyle at the individual, group, A program of leisure and educational activities is
population (societal), and government or implemented at a drop-in center for adults with
policy level (adapted from AOTA, 2020b). serious mental illness.

Population
Access to occupational therapy services is pro-
vided in underserved areas where residents
typically receive other services.
Health and wellness Health: State of physical, mental, and social Person
well-being, as well as a positive concept A person with a mental health challenge partici-
emphasizing social and personal resources pates in an empowerment and advocacy group to
and physical capacities (WHO, 1986). improve services in the community.
Health for groups and populations also A person with attention deficit hyperactivity dis-
includes social responsibility of members order demonstrates self-management through the
to the group or population as a whole. ability to manage the various aspects of their life.
Wellness: “Active process through which Group

individuals [or groups or populations] A company-wide program for employees is
become aware of and make choices toward implemented to identify problems and solutions
a more successful existence” (Hettler, 1984, regarding the balance among work, leisure, and
p. 1117). Wellness is more than a lack of family life.
disease symptoms; it is a state of mental
and physical balance and fitness (adapted Population
from “Wellness,” 1997, p. 2110) The incidence of childhood obesity decreases.
Quality of life Dynamic appraisal of the client’s life sat- Person

isfaction (perceptions of progress toward A deaf child from a hearing family participates
goals), hope (real or perceived belief that fully and actively during a recreational activity.
one can move toward a goal through se-
lected pathways), self-concept (composite Group
of beliefs and feelings about oneself), A facility experiences increased participation of
health and functioning (e.g., health status, residents during outings and independent travel
self-care capabilities), and socioeconomic as a result of independent living skills training for
factors (e.g., vocation, education, income; care providers.
adapted from Radomski, 1995)
Population
A lobby is formed to support opportunities for
social networking, advocacy activities, and
sharing of scientific information for stroke sur-
vivors and their families.
(Continued)
GUIDELINES

Participation Engagement in desired occupations in Person
ways that are personally satisfying and A person recovers the ability to perform the es-
congruent with expectations within the sential duties of his or her job after a flexor tendon
culture laceration.
Group
A family enjoys a vacation spent traveling cross-

country in their adapted van.
Population
All children within a state have access to school
sports programs.
Role competence Ability to effectively meet the demands of Person
the roles in which one engages A person with cerebral palsy is able to take notes
and type papers to meet the demands of the
student role.
Group
A factory implements job rotation to allow sharing
of higher demand tasks so employees can meet
the demands of the worker role.
Population
Accessibility of polling places is improved,
enabling all people with disabilities in the
community to meet the demands of the citizen
role.
Well-being Contentment with one’s health, self-es- Person
teem, sense of belonging, security, and A person with amyotrophic lateral sclerosis
opportunities for self-determination, achieves contentment with their ability to find
meaning, roles, and helping others meaning in fulfilling the role of parent through
(Hammell, 2009). Well-being is “a general compensatory strategies and environmental
term encompassing the total universe of modifications.
human life domains, including physical,
mental, and social aspects, that make up Group
what can be called a ‘good life’” (WHO, Members of an outpatient depression and anxiety
2006, p. 211). support group feel secure in their sense of group
belonging and ability to help other members.
Population
Residents of a town celebrate the groundbreaking
for a school being reconstructed after a natural
disaster.
(Continued)
GUIDELINES

Occupational justice Access to and participation in the full range Person
of meaningful and enriching occupations An individual with intellectual and developmental
afforded to others, including opportunities disabilities serves on an advisory board to es-
for social inclusion and resources to par- tablish programs to be offered by a community
ticipate in occupations to satisfy personal, recreation center.
health, and societal needs (adapted from
Townsend & Wilcock, 2004) Group

Workers have enough break time to eat lunch with
their young children in the day care center.
Group and Population

People with persistent mental illness experience
an increased sense of empowerment and self-
advocacy skills, enabling them to develop an
antistigma campaign promoting engagement in
the civic arena (group) and alternative adapted
housing options for older adults to age in place
(population).
Note. AOTA = American Occupational Therapy Association; WHO = World Health Organization.
Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.

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Authors
Cheryl Boop, MS, OTR/L
Susan M. Cahill, PhD, OTR/L, FAOTA
Charlotte Davis, MS, OTR/L
Julie Dorsey, OTD, OTR/L, CEAS, FAOTA
Varleisha Gibbs, PhD, OTD, OTR/L
Brian Herr, MOT, OTR/L
Kimberly Kearney, COTA/L
Elizabeth “Liz” Griffin Lannigan, PhD, OTR/L, FAOTA
Lizabeth Metzger, MS, OTR/L
Julie Miller, MOT, OTR/L, SWC
Amy Owens, OTR
Krysta Rives, MBA, COTA/L, CKTP
Caitlin Synovec, OTD, OTR/L, BCMH
Wayne L. Winistorfer, MPA, OTR, FAOTA
Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA Headquarters Liaison
for
The Commission on Practice

Julie Dorsey, OTD, OTR/L, CEAS, FAOTA, Chairperson
GUIDELINES
Acknowledgments
In addition to those named below, the COP thanks everyone who has contributed to the dialogue, feedback, and
concepts presented in the document. Sincerest appreciation is extended to AOTA Staff members Chris Davis,
Jennifer Folden, Caroline Polk, and Debbie Shelton for all their support. Further appreciation and thanks are
extended to Anne G. Fisher, ScD, OT, FAOTA; Lou Ann Griswold, PhD, OTR/L, FAOTA; and Abbey Marterella, PhD,
OTR/L.

The COP wishes to acknowledge the authors of the third edition of this document: Deborah Ann Amini, EdD, OTR/L,
CHT, FAOTA, Chairperson, 2011–2014; Kathy Kannenberg, MA, OTR/L, CCM, Chairperson-Elect, 2013–2014;
Stefanie Bodison, OTD, OTR/L; Pei-Fen Chang, PhD, OTR/L; Donna Colaianni, PhD, OTR/L, CHT; Beth Goodrich,
OTR, ATP, PhD; Lisa Mahaffey, MS, OTR/L, FAOTA; Mashelle Painter, MEd, COTA/L; Michael Urban, MS, OTR/L,
CEAS, MBA, CWCE; Dottie Handley-More, MS, OTR/L, SIS Liaison; Kiel Cooluris, MOT, OTR/L, ASD Liaison;
Andrea McElroy, MS, OTR/L, Immediate-Past ASD Liaison; Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA
Headquarters Liaison.
The COP wishes to acknowledge the authors of the second edition of this document: Susanne Smith Roley, MS, OTR/L,
FAOTA, Chairperson, 2005–2008; Janet V. DeLany, DEd, OTR/L, FAOTA; Cynthia J. Barrows, MS, OTR/L; Susan
Brownrigg, OTR/L; DeLana Honaker, PhD, OTR/L, BCP; Deanna Iris Sava, MS, OTR/L; Vibeke Talley, OTR/L; Kristi
Voelkerding, BS, COTA/L, ATP; Deborah Ann Amini, MEd, OTR/L, CHT, FAOTA, SIS Liaison; Emily Smith, MOT, ASD
Liaison; Pamela Toto, MS, OTR/L, BCG, FAOTA, Immediate-Past SIS Liaison; Sarah King, MOT, OTR, Immediate-Past
ASD Liaison; Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA Headquarters Liaison; with contributions from
M. Carolyn Baum, PhD, OTR/L, FAOTA; Ellen S. Cohn, ScD, OTR/L, FAOTA; Penelope A. Moyers Cleveland, EdD,
OTR/L, BCMH, FAOTA; and Mary Jane Youngstrom, MS, OTR, FAOTA.
The COP also wishes to acknowledge the authors of the first edition of this document: Mary Jane Youngstrom, MS, OTR,
FAOTA, Chairperson (1998–2002); Sara Jane Brayman, PhD, OTR, FAOTA, Chairperson-Elect (2001–2002); Paige
Anthony, COTA; Mary Brinson, MS, OTR/L, FAOTA; Susan Brownrigg, OTR/L; Gloria Frolek Clark, MS, OTR/L,
FAOTA; Susanne Smith Roley, MS, OTR; James Sellers, OTR/L; Nancy L. Van Slyke, EdD, OTR; Stacy M. Desmarais,
MS,OTR/L, ASD Liaison; Jane Oldham, MOTS, Immediate-Past ASCOTA Liaison; Mary Vining Radomski, MA, OTR,
FAOTA, SIS Liaison; Sarah D. Hertfelder, MEd, MOT, OTR, FAOTA, National Office Liaison.
Revised by the Commission on Practice, 2020
Adopted by the Representative Assembly May, 2020
Note. This document replaces the 2014 Occupational Therapy Practice Framework: Domain and Process (3rd ed.). Published in the American
Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://dx.doi.org/10.5014/ajot.2020.74S2001
Copyright © 2020 by the American Occupational Therapy Association.
Citation: American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American
Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001
GUIDELINES
Appendix A. Glossary
A
Activities
Actions designed and selected to support the development of performance skills and performance patterns to enhance
occupational engagement.

Activities of daily living (ADLs)
Activities that are oriented toward taking care of one’s own body (adapted from Rogers & Holm, 1994) and are
completed on a daily basis. These activities are “fundamental to living in a social world; they enable basic survival and
well-being” (Christiansen & Hammecker, 2001, p. 156; see Table 2).
Activity analysis
Generic and decontextualized analysis that seeks to develop an understanding of typical activity demands within a
given culture.
Activity demands
Aspects of an activity needed to carry it out, including relevance and importance to the client, objects used and their
properties, space demands, social demands, sequencing and timing, required actions and performance skills, and
required underlying body functions and body structures (see Table 11).
Adaptation
Effective and efficient response by the client to occupational and contextual demands (Grajo, 2019).
Advocacy
Efforts directed toward promoting occupational justice and empowering clients to seek and obtain resources to fully
participate in their daily life occupations. Efforts undertaken by the practitioner are considered advocacy, and those
undertaken by the client are considered self-advocacy and can be promoted and supported by the practitioner (see
Table 12).
Analysis of occupational performance

The step in the evaluation process in which the client’s assets and limitations or potential problems are more specifically
determined through assessment tools designed to analyze, measure, and inquire about factors that support or hinder
occupational performance (see Exhibit 2).
Assessment
“A specific tool, instrument, or systematic interaction . . . used to understand a client’s occupational profile, client factors,
performance skills, performance patterns, and contextual and environmental factors, as well as activity demands that
influence occupational performance” (Hinojosa et al., 2014, pp. 3–4).
GUIDELINES
Belief
Something that is accepted, considered to be true, or held as an opinion (“Belief,” 2020).
Body functions
“Physiological functions of body systems (including psychological functions)” (World Health Organization, 2001, p. 10;
see Table 9).

Body structures
“Anatomical parts of the body, such as organs, limbs, and their components” that support body functions (World Health
Organization, 2001, p. 10; see Table 9).
Client
Person (including one involved in the care of a client), group (collection of individuals having shared characteristics or
common or shared purpose, e.g., family members, workers, students, and those with similar interests or occupational
challenges), or population (aggregate of people with common attributes such as contexts, characteristics, or concerns,
including health risks; Scaffa & Reitz, 2014).
Client-centered care (client-centered practice)

Approach to service that incorporates respect for and partnership with clients as active participants in the therapy
process. This approach emphasizes clients’ knowledge and experience, strengths, capacity for choice, and overall
autonomy (Schell & Gillen, 2019, p. 1194).
Client factors
Specific capacities, characteristics, or beliefs that reside within the person and that influence performance in occu-
pations. Client factors include values, beliefs, and spirituality; body functions; and body structures (see Table 9).
Clinical reasoning
See Professional reasoning
Collaboration
“The complex interpretative acts in which the practitioners must understand the meanings of the interventions, the
meanings of illness or disability in a person and family’s life, and the feelings that accompany these experiences”
(Lawlor & Mattingly, 2019, p. 201).
Community
Collection of populations that is changeable and diverse and includes various people, groups, networks, and orga-
nizations (Scaffa, 2019; World Federation of Occupational Therapists, 2019).
GUIDELINES
Context
Construct that constitutes the complete makeup of a person’s life as well as the common and divergent factors
that characterize groups and populations. Context includes environmental factors and personal factors (see Tables 4
and 5).
Co-occupation
Occupation that implicitly involves two or more individuals (Schell & Gillen, 2019, p. 1195) and includes aspects of
physicality, emotionality, and intentionality (Pickens & Pizur-Barnekow, 2009).

Cornerstone
Something of significance on which everything else depends.
Domain
Profession’s purview and areas in which its members have an established body of knowledge and expertise.
Education
As an occupation: Activities involved in learning and participating in the educational environment (see Table 2).
As an environmental factor of context: Processes and methods for acquisition of knowledge, expertise, or skills (see
Table 4).
As an intervention: Activities that impart knowledge and information about occupation, health, well-being, and par-
ticipation, resulting in acquisition by the client of helpful behaviors, habits, and routines that may or may not require
application at the time of the intervention session (see Table 12).
Empathy
Emotional exchange between occupational therapy practitioners and clients that allows more open communication,
ensuring that practitioners connect with clients at an emotional level to assist them with their current life situation.
Engagement in occupation
Performance of occupations as the result of choice, motivation, and meaning within a supportive context.
Environmental factors
Aspects of the physical, social, and attitudinal surroundings in which people live and conduct their lives.
Evaluation
“The comprehensive process of obtaining and interpreting the data necessary to understand the person, system, or
situation. . . . Evaluation requires synthesis of all data obtained, analytic interpretation of that data, reflective
clinical reasoning, and consideration of occupational performance and contextual factors” (Hinojosa et al., 2014,
p. 3).
GUIDELINES
Goal
Measurable and meaningful, occupation-based, long-term or short-term aim directly related to the client’s ability and
need to engage in desired occupations (AOTA, 2018a, p. 4).
Group
Collection of individuals having shared characteristics or a common or shared purpose (e.g., family members, workers,

students, others with similar occupational interests or occupational challenges).
Group intervention
Use of distinct knowledge and leadership techniques to facilitate learning and skill acquisition across the lifespan
through the dynamics of group and social interaction. Groups may be used as a method of service delivery (see
Table 12).
Habilitation
Health care services that help a person keep, learn, or improve skills and functioning for daily living (e.g., therapy for a
child who does not walk or talk at the expected age). These services may include physical and occupational therapy,
speech-language pathology, and other services for people with disabilities in a variety of inpatient and outpatient
settings (“Provision of EHB,” 2015).
Habits
“Specific, automatic behaviors performed repeatedly, relatively automatically, and with little variation” (Matuska &
Barrett, 2019, p. 214). Habits can be healthy or unhealthy, efficient or inefficient, and supportive or harmful (Dunn, 2000).
Health
“State of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (World
Health Organization, 2006, p. 1).
Health management
Occupation focused on developing, managing, and maintaining routines for health and wellness by engaging in self-
care with the goal of improving or maintaining health, including self-management, to allow for participation in other
occupations (see Table 2).
Health promotion
“Process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical,
mental, and social well-being, an individual or group must be able to identify and realize aspirations, to satisfy needs,
and to change or cope with the environment” (World Health Organization, 1986).
Hope
Real or perceived belief that one can move toward a goal through selected pathways.
GUIDELINES
Independence
“Self-directed state of being characterized by an individual’s ability to participate in necessary and preferred occupations
in a satisfying manner irrespective of the amount or kind of external assistance desired or required” (AOTA, 2002a, p.
660).
Instrumental activities of daily living (IADLs)

Activities that support daily life within the home and community and that often require more complex interactions than
those used in ADLs (see Table 2).
Interdependence
“Reliance that people have on one another as a natural consequence of group living” (Christiansen & Townsend, 2010,
p. 419). “Interdependence engenders a spirit of social inclusion, mutual aid, and a moral commitment and responsibility
to recognize and support difference” (Christiansen & Townsend, 2010, p. 187).
Interests
“What one finds enjoyable or satisfying to do” (Kielhofner, 2008, p. 42).
Intervention
“Process and skilled actions taken by occupational therapy practitioners in collaboration with the client to facilitate
engagement in occupation related to health and participation. The intervention process includes the plan, imple-
mentation, and review” (AOTA, 2015c, p. 2).
Intervention approaches
Specific strategies selected to direct the process of interventions on the basis of the client’s desired outcomes,
evaluation data, and evidence (see Table 13).
Interventions to support occupations

Methods and tasks that prepare the client for occupational performance, used as part of a treatment session in
preparation for or concurrently with occupations and activities or provided to a client as a home-based engagement to
support daily occupational performance (see Table 12).
Leisure
“Nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time
not committed to obligatory occupations such as work, self-care, or sleep” (Parham & Fazio, 1997, p. 250; see
Table 2).
GUIDELINES
Motor skills
The “group of performance skills that represent small, observable actions related to moving oneself or moving and
interacting with tangible task objects (e.g., tools, utensils, clothing, food or other supplies, digital devices, plant life) in the
context of performing a personally and ecologically relevant daily life task. They are commonly named in terms of type of
task being performed (e.g., [activity of daily living] motor skills, school motor skills, work motor skills)” (Fisher &
Marterella, 2019, p. 331; see Table 7).

O
Occupation
Everyday personalized activities that people do as individuals, in families, and with communities to occupy time and
bring meaning and purpose to life. Occupations can involve the execution of multiple activities for completion and can
result in various outcomes. The broad range of occupations is categorized as activities of daily living, instrumental
activities of daily living, health management, rest and sleep, education, work, play, leisure, and social participation (see
Table 2).
Occupation-based
Characteristic of the best practice method used in occupational therapy, in which the practitioner uses an evaluation
process and types of interventions that actively engage the client in occupation (Fisher & Marterella, 2019).
Occupational analysis
Analysis that is performed with an understanding of “the specific situation of the client and therefore [of] the specific
occupations the client wants or needs to do in the actual context in which these occupations are performed” (Schell
et al., 2019, p. 322).
Occupational demands
Aspects of an activity needed to carry it out, including relevance and importance to the client, objects used and their
properties, space demands, social demands, sequencing and timing, required actions and performance skills, and
required underlying body functions and body structures (see Table 10).
Occupational identity
“Composite sense of who one is and wishes to become as an occupational being generated from one’s history of
occupational participation” (Schell & Gillen, 2019, p. 1205).
Occupational justice
“A justice that recognizes occupational rights to inclusive participation in everyday occupations for all persons in society,
regardless of age, ability, gender, social class, or other differences” (Nilsson & Townsend, 2010, p. 58). Occupational
justice includes access to and participation in the full range of meaningful and enriching occupations afforded to others,
including opportunities for social inclusion and the resources to participate in occupations to satisfy personal, health,
and societal needs (adapted from Townsend & Wilcock, 2004).
GUIDELINES
Occupational performance
Accomplishment of the selected occupation resulting from the dynamic transaction among the client, their context, and
the occupation.
Occupational profile
Summary of the client’s occupational history and experiences, patterns of daily living, interests, values, needs, and
relevant contexts (see Exhibit 2).

Occupational science
“Way of thinking that enables an understanding of occupation, the occupational nature of humans, the relationship
between occupation, health and wellbeing, and the influences that shape occupation” (World Federation of
Occupational Therapists, 2012b, p. 2).
Occupational therapy
Therapeutic use of everyday life occupations with persons, groups, or populations (i.e., clients) for the purpose of
enhancing or enabling participation. Occupational therapy practitioners use their knowledge of the transactional re-
lationship among the person, their engagement in valued occupations, and the context to design occupation-based
intervention plans. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health
and wellness for clients with disability- and non-disability-related needs. Services promote acquisition and preservation
of occupational identity for those who have or are at risk for developing an illness, injury, disease, disorder, condition,
impairment, disability, activity limitation, or participation restriction (adapted from American Occupational Therapy
Association, 2011).
Organization
Entity composed of individuals with a common purpose or enterprise, such as a business, industry, or agency.
Outcome
Result clients can achieve through the occupational therapy process (see Table 14).
Participation
“Involvement in a life situation” (World Health Organization, 2001, p. 10).
Performance patterns
Habits, routines, roles, and rituals that may be associated with different lifestyles and used in the process of engaging in
occupations or activities. These patterns are influenced by context and time and can support or hinder occupational
performance (see Table 6).
Performance skills
Observable, goal-directed actions that result in a client’s quality of performing desired occupations. Skills are supported
by the context in which the performance occurred and by underlying client factors (Fisher & Marterella, 2019).
GUIDELINES
Person
Individual, including family member, caregiver, teacher, employee, or relevant other.
Personal factors
Unique features of the person reflecting the particular background of their life and living that are not part of a health
condition or health state. Personal factors are generally considered to be enduring, stable attributes of the person,
although some personal factors may change over time (see Table 5).

Play
Active engagement in an activity that is intrinsically motivated, internally controlled, and freely chosen and that may
include the suspension of reality (Skard & Bundy, 2008). Play includes participation in a broad range of experiences
including but not limited to exploration, humor, fantasy, risk, contest, and celebrations (Eberle, 2014; Sutton-Smith,
2009). Play is a complex and multidimensional phenomenon that is shaped by sociocultural factors (Lynch et al., 2016;
see Table 2).
Population
Aggregate of people with common attributes such as contexts, characteristics, or concerns, including health risks.
Prevention
Education or health promotion efforts designed to identify, reduce, or prevent the onset and decrease the incidence of
unhealthy conditions, risk factors, diseases, or injuries (American Occupational Therapy Association, 2020a).
Process
Series of steps occupational therapy practitioners use to operationalize their expertise in providing services to clients.
The occupational therapy process includes evaluation, intervention, and outcomes; occurs within the purview of the
occupational therapy domain; and involves collaboration among the occupational therapist, occupational therapy
assistant, and client.
Process skills
The “group of performance skills that represent small, observable actions related to selecting, interacting with, and using
tangible task objects (e.g., tools, utensils, clothing, food or other supplies, digital devices, plant life); carrying out
individual actions and steps; and preventing problems of occupational performance from occurring or reoccurring in the
context of performing a personally and ecologically relevant daily life task. They are commonly named in terms of type of
task being performed (e.g., [activity of daily living] process skills, school process skills, work process skills)” (Fisher &
Marterella, 2019, pp. 336–337; see Table 7).
Professional reasoning
“Process that practitioners use to plan, direct, perform, and reflect on client care” (Schell, 2019, p. 482).
GUIDELINES
Quality of life
Dynamic appraisal of life satisfaction (perception of progress toward identifying goals), self-concept (beliefs and feelings
about oneself), health and functioning (e.g., health status, self-care capabilities), and socioeconomic factors (e.g.,
vocation, education, income; adapted from Radomski, 1995).

Reevaluation
Reappraisal of the client’s performance and goals to determine the type and amount of change that has taken
place.
Rehabilitation
Services provided to persons experiencing deficits in key areas of physical and other types of function or limitations in
participation in daily life activities. Interventions are designed to enable the achievement and maintenance of optimal
physical, sensory, intellectual, psychological, and social functional levels. Rehabilitation services provide tools and
techniques clients need to attain desired levels of independence and self-determination.
Rituals
For persons: Sets of symbolic actions with spiritual, cultural, or social meaning contributing to the client’s identity and
reinforcing values and beliefs. Rituals have a strong affective component (Fiese, 2007; Fiese et al., 2002; Segal, 2004;
see Table 6).
For groups and populations: Shared social actions with traditional, emotional, purposive, and technological meaning
contributing to values and beliefs within the group or population (see Table 6).
Roles
For persons: Sets of behaviors expected by society and shaped by culture and context that may be further con-
ceptualized and defined by the client (see Table 6).
For groups and populations: Sets of behaviors by the group or population expected by society and shaped
by culture and context that may be further conceptualized and defined by the group or population
(see Table 6).
Routines
For persons, groups, and populations: Patterns of behavior that are observable, regular, and repetitive and
that provide structure for daily life. They can be satisfying and promoting or damaging. Routines require
momentary time commitment and are embedded in cultural and ecological contexts (Fiese et al., 2002; Segal, 2004;
see Table 6).
GUIDELINES
Screening
“Process of reviewing available data, observing a client, or administering screening instruments to identify a person’s (or
a population’s) potential strengths and limitations and the need for further assessment” (Hinojosa et al., 2014, p. 3).
Self-advocacy
Advocacy for oneself, including making one’s own decisions about life, learning how to obtain information to gain an

understanding about issues of personal interest or importance, developing a network of support, knowing one’s rights
and responsibilities, reaching out to others when in need of assistance, and learning about self-determination.
Service delivery
Set of approaches and methods for providing services to or on behalf of clients.
Skilled services
To be covered as skilled therapy, services must require the skills of a qualified occupational therapy practitioner and
must be reasonable and necessary for the treatment of the patient’s condition, illness, or injury. Skilled therapy services
may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or
slow further deterioration of the patient’s condition. Practitioners should check their payer policies to ensure they meet
payer definitions and comply with payer requirements.
Social interaction skills

The “group of performance skills that represent small, observable actions related to communicating and interacting with
others in the context of engaging in a personally and ecologically relevant daily life task performance that involves social
interaction with others” (Fisher & Marterella, 2019, p. 342).
Social participation
“Interweaving of occupations to support desired engagement in community and family activities as well as those
involving peers and friends” (Schell & Gillen, 2019, p. 711) involvement in a subset of activities that incorporate social
situations with others (Bedell, 2012) and that support social interdependence (Magasi & Hammel, 2004; see Table 2).
Spirituality
“Deep experience of meaning brought about by engaging in occupations that involve the enacting of personal values
and beliefs, reflection, and intention within a supportive contextual environment” (Billock, 2005, p. 887). It is important to
recognize spirituality “as dynamic and often evolving” (Humbert, 2016, p. 12).
Time management
Manner in which a person, group, or population organizes, schedules, and prioritizes certain activities.
Transaction
Process that involves two or more individuals or elements that reciprocally and continually influence and affect one
another through the ongoing relationship (Dickie et al., 2006).
GUIDELINES
Values
Acquired beliefs and commitments, derived from culture, about what is good, right, and important to do (Kielhofner,
2008).

Well-being
“General term encompassing the total universe of human life domains, including physical, mental, and social aspects,
that make up what can be called a ‘good life’” (World Health Organization, 2006, p. 211).
Wellness
“The individual’s perception of and responsibility for psychological and physical well-being as these contribute to overall
satisfaction with one’s life situation” (Schell & Gillen, 2019, p. 1215).
Work
Labor or exertion related to the development, production, delivery, or management of objects or services; benefits may
be financial or nonfinancial (e.g., social connectedness, contributions to society, adding structure and routine to daily
life; Christiansen & Townsend, 2010; Dorsey et al., 2019).
GUIDELINES
Index
Note: Page numbers in italic refer to exhibits, figures, and tables.
activities beliefs, 51 performance patterns, 12–13

defined, 74 body functions and body performance skills, 12–15
interventions for, 59 structures, 51–54 personal factors, 10–11
activities of daily living (ADLs) defined, 75 dressing, 30
overview, 30, 74 domain and, 15 driving, 31

examples, 35 spirituality, 51
activity analysis, 19–20, 74 values, 51 eating and swallowing, 30
activity demands, 57–58, 74 client-centered care (client-centered education
adaptation, 74 practice), 75 overview, 33, 76
advocacy, 61–62, 74 clients examples, 35
American Occupational Therapy defined, 75 interventions for, 61
Association (AOTA) examples, 29 empathy, 76
Commission on Practice terminology, 2, 24 employment, 33–34. see also
(COP), 3 clinical reasoning, 20, 75 work
Representative Assembly Commission on Practice (COP), 3 engagement in occupation, 5–6,
(RA), 2–3 communication management, 31 76
analysis of occupational perfor- communication with the health enhancement, 65–66
mance, 74 care system, 32 environmental factors, 9–10,
animals, 31 community, 2, 75 36–39, 76
assessment, 74 community mobility, 29, 31 environmental modifications, 60
assistive technology (AT), 60 community participation, 34 episodic care, 19
consumers, 24 evaluation
bathing, 30 context overview, 23, 76
beliefs defined, 76 process, 16, 55
defined, 15, 75 environmental factors, 36–39 synthesis of, 23
occupational performance and, personal factors, 40
51 co-occupations, 76 family participation, 34
body functions and body cornerstones of occupational family-centered care approaches,
structures therapy practice, 6, 76 19
overview, 15, 75 feeding, 29, 30
occupational performance and, direct services, 18 financial management, 31
51–54 discontinuation, 27 friendships, 34
domain functional mobility, 30
cardiovascular system functions, 53 aspects of, 5, 6
care of others, 30 client factors, 15 goals, 77
care of pets and animals, 31 defined, 76 group interventions, 62, 77
case management, 19 environmental factors, 9–10 groups
child rearing, 31 occupational justice, 11–12 defined, 2, 77
client factors occupations and, 6–9 examples, 29
GUIDELINES
performance patterns, 41–42 virtual interventions, 62 Reporting Occupational

performance skills and, 14, 50 intimate partner relationships, 34 Therapy Services, 2
process, 55–56 occupation-based practice, 79
job performance and
The Guide to Occupational occupations
maintenance, 33. see also work
Therapy Practice (Moyers), 3 activities of daily living (ADLs), 30, 35
leisure defined, 79
habilitation, 77 domain and, 6–9
overview, 34, 78
habits, 12, 41, 77 education, 33, 35
examples, 35

health and wellness, 5, 66, 77 health management, 32, 35
health management meal preparation and cleanup, 31 instrumental activities of daily living
overview, 32 medication management, 32 (IADLs), 30–31, 35
defined, 77 members, 24 interventions for, 59
examples, 29, 35 mental functions, 52 leisure, 34, 35
health promotion, 24, 77 motor skills, 13, 43–44, 50, 79 play, 34, 35
hematological and immune movement-related functions, 53 rest and sleep, 32–33, 35
system functions, 53 social participation, 34, 35
home establishment and neuromusculoskeletal functions, 53 work, 33–34, 35
management, 29, 31 nutrition management, 32 organization, 80
hope, 77 organization-level practice, 19
occupational adaptation, 26
orthotics and prosthetics, 60
immune system functions, 53 occupational analysis, 19–20, 79
outcomes
improvement, 65 occupational demands, 79
overview, 26–27, 80
independence, 78 occupational identity, 79
descriptions and examples, 65–68
indirect services, 18–19 occupational justice, 11–12,
process, 17, 56
instrumental activities of daily 67–68, 79
living (IADLs) occupational performance PAMs and mechanical modalities, 59
overview, 30–31, 78 analysis, 16, 23 participation, 5, 67, 80
examples, 35 client factors, 51–54 patient-reported outcomes
interdependence, 78 defined, 80 (PROs), 27. see also outcomes
interests, 78 outcomes, 65 patients, 24
intervention occupational profile, 16, 21–22, 80 peer group participation, 34
approaches to, 63–64, 78 occupational science, 80 performance patterns, 12–13,
defined, 78 occupational therapy, 1, 4, 80 41–42, 80
for education, 61 Occupational Therapy Code of performance skills
group interventions, 62 Ethics, 24 defined, 81
intervention implementation, 25 occupational therapy practice domain and, 12–15
intervention plan, 24–25 cornerstones, 6 motor skills, 13, 43–44, 50
intervention review, 25 occupational therapy process skills, 13, 44–47, 50
process, 16–17, 23–26, 55–56 practitioners, 1 social interaction skills, 13, 47–49
supporting occupations, 78 Occupational Therapy Product personal care device management, 32
for training, 61 Output Reporting System and personal factors, 10–11, 40, 81
types of, 59–62 Uniform Terminology for personal hygiene and grooming, 30
GUIDELINES
persons telehealth, 19 social participation

defined, 2, 81 therapeutic use of self, 20 overview, 34, 83
examples, 29 process skills examples, 29, 35
performance patterns, 41 overview, 13, 81 speech functions, 54
performance skills and, 14, 43–49 performance skills, 44–47, 50 spiritual expression, 31
process, 55–56 professional reasoning, 20, 81 spirituality
pets and animals, 31 prosthetics, 60 defined, 15, 83
physical activity, 32 occupational performance and, 51

play quality of life, 66, 82 Standards of Practice for
overview, 34, 81 Occupational Therapy, 24
examples, 35 reevaluation, 82 students, 24
populations rehabilitation, 82 swallowing, 30
defined, 2, 81 religious and spiritual symptom and condition
examples, 29 expression, 31 management, 32
performance patterns, 41–42 Representative Assembly (RA), 2–3 systems-level practice, 19
performance skills and, 15 respiratory system functions, 53
process, 55–56 rest and sleep, 32–33, 35 telehealth, 19, 62
prevention, 66, 81 retirement preparation and therapeutic use of self, 20
process adjustment, 34 time, time management and time
overview, 15–19 revisions, 3–4 use, 12, 83
activity analysis, 19–20 rituals, 12, 41–42, 82 toileting and toilet hygiene, 30
aspects of, 5 role competence, 67 training interventions, 61
case management, 19 roles, 12, 41–42, 82 transaction, 83
clinical reasoning, 20 routines, 12, 41, 82 transition, 27
defined, 81
Uniform Terminology for Oc-
direct services, 18 safety and emergency
cupational Therapy, 2
episodic care, 19 maintenance, 31
evaluation, 16, 23 screening, 83 values
family-centered care approaches, 19 self-advocacy, 62, 83 defined, 15, 84
groups, 55–56 self-regulation, 60 occupational performance and, 51
indirect services, 18–19 sensory functions, 52–53 virtual interventions, 62
intervention, 16–17, 23–26 service delivery, 18–19, 83 voice and speech functions, 54
occupational analysis, 19–20 sexual activity, 30 volunteer exploration and
occupational performance, 16 shopping, 31 participation, 34
occupational profile, 16 showering, 30
organization-level practice, 19 skilled services, 83 well-being, 5, 67, 84
outcomes, 17 skin and related structure functions, 54 wellness, 84
persons, 55–56 sleep, 33. see also rest and sleep wheeled mobility, 60
populations, 55–56 social and emotional health work
professional reasoning, 20 promotion and maintenance, 32 overview, 33–34, 84
service delivery approaches, 18–19 social interaction skills, 13, examples, 35
systems-level practice, 19 47–49, 83 work participation, examples, 29

Occupational Therapy Practice Framework: Domain and Process Fourth Edition

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GUIDELINES

Occupational Therapy Practice

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Figure 1. Occupational Therapy Domain and Process

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environmental and personal factors). Engagement Occupational therapy cornerstones provide a

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Exhibit 1. Aspects of the Occupational Therapy Domain

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AOTA OFFICIAL DOCUMENT 13

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Exhibit 2. Operationalizing the Occupational Therapy Process

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Analysis of Occupational Performance

Synthesis of Evaluation Process

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Exhibit 2. Operationalizing the Occupational Therapy Process (cont’d)

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AOTA OFFICIAL DOCUMENT 19

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AOTA OFFICIAL DOCUMENT 23

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