Evaluation and Referral
Who does what
A referral triggers a chain: chart review, screening, occupational profile, data collection, and the occupational therapist's synthesis into a plan of care. The COTA's contribution is real but bounded - you gather data, conduct caregiver interviews, observe performance, and administer assessments when the supervising OT has established service competency for that tool. You do not interpret standardized scores into a diagnosis, select the evaluation battery, or write the initial plan of care. Answer choices that assign those tasks to the COTA are almost always wrong.
What to gather
Distinguish top-down (start with the occupations the client needs and values) from bottom-up (impairment-level measures such as ROM, MMT, tone, sensation) approaches; strong answers tie impairment findings back to occupational performance. Know the occupational profile, standardized versus nonstandardized tools, reliability and validity, and contextual factors - physical, social, cultural, institutional. Interview and observation are core skills: a client who says "I'm fine" while unable to don shoes has just given you data.
Referral beyond OT
Screen for problems needing another discipline or a physician: new skin breakdown, unexplained bruising, sudden strength or speech change, uncontrolled pain, vision or hearing loss, depression, unsafe home situation. Document the finding and report it to the OT and the appropriate team member; do not silently alter the plan.
Rule of thumb: collect, don't conclude. If an option has the COTA interpreting results, establishing the POC, or diagnosing, eliminate it.
Worked example: During an ADL session you notice new sacral redness in a patient taking warfarin. Correct response: reposition, document, notify the OT and nursing/physician - not to keep treating and mention it at week's end.