1. Evaluation
   1. Medical & Therapy History
      1. Presenting Problem
         1. General Health Status
            1. Medical Conditions & Co-morbidities
            2. Pain Scale
            3. Surgical History
            4. Allergies, Meds, and Tests
            5. Therapy History
            6. Social and Health Habits (past and current)
   2. Occupational Profile
      1. Client Report
         1. Reason for Seeking Service
            1. Occupations in which the client is successful
            2. Personal Interests and values
            3. Occupational History
            4. Performance Patterns; Routines, Roles, Habits, and Rituals
      2. Environment/Context
         1. Supports and Barriers
            1. Living Environment
            2. Available Social Support
            3. Equipment
      3. Client Goals
   3. Analysis of Occupational Performance
      1. Occupations (Performance Deficits)
         1. Interactive table to record assessment of occupation in EMR
      2. Client Factors
         1. Body functions and structures interactive table for EMR
      3. Performance Skills
         1. Interactive table to record assessment of performance skills in EMR
      4. Context/Environment
         1. Interactive table to record assessment of context/environment in EMR
      5. Assessment Records Repository
   4. Intervention/ Plan of Care
      1. Analysis of Findings
         1. Strengths
            1. Weaknesses
            2. Prognosis
            3. Frames of Reference
            4. Summary
      2. Problems
         1. Problem Builder
      3. Goals
         1. Goal Builder
            1. Goal Summary
      4. Intervention
      5. Anticipated Discharge
      6. Medical Necessity
2. used to fill out electronic medical records