How to write an occupational therapy home assessment report

Who reads the report, and what each reader needs

The report is one document doing four jobs, and most of the problems with home assessment reports come from writing it for only one of the readers.

• The client and their family need to understand what was found, why each change is recommended, and what happens next. They will read the summary and the recommendations and skip the measurements.
• The funder (a provincial home modification program, an insurer, Veterans Affairs Canada, a First Nations and Inuit Health Branch regional office, a workers' compensation board, or the client's own budget) needs the clinical rationale tied to each item, usually in its own form and its own order. A recommendation without a rationale is the most common reason an item is declined.
• The contractor or equipment vendor needs the measurements: the clear width of the doorway, the height of the tub rim, where the grab bar goes and how long it is. If the numbers are missing, someone drives back to the house to take them.
• The OT's own record has to meet the documentation standards of their regulatory college. That means the report shows the reasoning, is dated and signed, and would let another clinician understand what was done and why.

CAOT's 2024 practice document on home assessment and modifications describes the OT as the professional who evaluates both the person (transfers, mobility, balance, vision, attention) and the environment, and then recommends equipment, physical modifications, assistive technology and changes to routines (source 1). The report is where that evaluation becomes something other people can act on.

The sections a home assessment report needs

Templates differ by employer and by funder, and a funder's own form always wins. Underneath the formatting, a complete report answers the same set of questions in roughly this order.

1. Referral and purpose. Who referred the client, what question the assessment is meant to answer (discharge planning, a fall, a new diagnosis, a funding application), and the date and location of the visit.
2. Client background and function. Diagnosis and relevant history, current mobility and transfers, cognition and vision where they affect safety, who else lives in the home, and what the client wants to be able to do. Keep this to what bears on the home; the rest belongs in the clinical file.
3. Home overview. Type of dwelling, ownership or tenancy (this decides what can be modified), entrances, levels, and how the client currently gets in and out and between floors.
4. Room-by-room findings. For each room the client uses: what was observed, the measurements that matter there, the hazards, and a photo tied to each finding. Bathroom, bedroom, entrances and stairs carry most of the risk. A 2021 analysis of United States emergency department visits found that where the location of an older adult's fall was recorded, nearly four in five happened at home, most often in the bedroom, the bathroom or on stairs (source 4).
5. Functional observations. What the client was asked to do during the visit (a tub transfer, the front steps, reaching a cupboard) and how it went. Observed performance carries more weight with funders than reported performance.
6. Recommendations. Each item on its own line with the finding it addresses, the clinical rationale, the specification (product type, dimensions, placement), and who installs or supplies it. Separate immediate safety items from longer-term modifications so the urgent things do not wait for a grant decision.
7. Funding and next steps. Which program or payer each recommendation is being submitted to, which forms accompany the report, and who does what next, including any follow-up visit.
8. Signature and credentials. Name, designation, registration number where the college requires it, contact details, and the date.

Which measurements to record

Record every measurement the recommendations depend on, in millimetres or inches consistently, and say which. The table below is the working list most OTs carry into a home. Where a Canadian accessibility standard gives a figure, it is included as a reference point only: CSA/ASC B651 and the federal model standard are written for public and federally regulated buildings, not private homes, and the right height for a particular client's grab bar is a clinical decision that depends on that client (source 2, source 3).

Tie each measurement to a photo. A photo of the tub with the rim height written on it is worth a paragraph to the contractor and to the funder's reviewer, who has usually never seen the house.

The mistakes that get reports sent back

Funders decline items and contractors make second visits for a short list of reasons, and all of them are avoidable at the desk.

• A recommendation with no finding behind it. "Install grab bars in the bathroom" is a shopping list. "Client requires two-handed support to rise from the toilet; recommend a horizontal grab bar on the left wall, 600 mm, at 800 mm from the floor" is a clinical recommendation.
• Frame width recorded instead of clear width. The door, the stop and the hinge side all take space out of the opening. Measure with the door open, from the face of the door to the stop.
• The funder's form filled in from memory the next week. Details drift. Fill the form from the same notes and photos as the report, ideally in the same sitting.
• Reported function presented as observed function. If the client said they manage the stairs but the OT did not watch them, the report should say so.
• No separation of urgent and eventual. A loose rug and a bath mat can be dealt with today. A ramp waits for a grant. If they sit in one list, the urgent items wait too.
• Photos with no captions. Twelve photos of a bathroom mean nothing to a reviewer without the finding each one shows.

Where the time goes

The visit itself is usually an hour or so. The report is the rest of the working day, and the reason is not the writing. It is the reconstruction: turning handwritten notes and a phone full of photos into a room-by-room account, re-reading the notes to find the tub rim height, matching photos to findings, and then entering the same information a second time into the funder's form, in the funder's order. Anything that captures the measurements and photos in a structured way during the visit shortens the afternoon, whether that is a printed checklist, a tablet form, or an assistant that does it for you.

Common questions