The Levels of Assistance in Occupational Therapy: What to Know

At the beginning of your journey into occupational therapy (whether you are a student or new grad OT practitioner), it can be challenging to quantify the levels of assistance your patient is requiring within their activities of daily living (ADLs).

You might be able to provide a wordy explanation about how much assistance your patient needed from you while putting on his pants, but how exactly can you concisely relay that information to another health care practitioner or track the progress in an objective manner?

We’ve got you covered here. We’ll be highlighting the different levels of assistance we use in occupational therapy and give you a few documentation examples as well. Let’s start at the beginning:

First, What are ADLs?

Activities of daily living (ADLs) is a term coined to collectively describe skills used to independently care for yourself. It can be divided into your basic ADLs (your self-care tasks) and your instrumental ADLs (activities to be independent within society and your community).

How ADLs are differentiated:

Basic ADLs (BADLs)

• Feeding
• Grooming (brushing teeth and hair, shaving, doing nails etc.)
• Toileting
• Dressing
• Bathing/showering
• Transferring
• Walking/functional mobility

Instrumental ADLs (IADLs)

• Financial management
• Medication management
• Housework
• Shopping and meal preparation
• Health management
• Outdoor/community functional mobility
• Managing transportation

For more detailed information on the difference between ADLs vs IADLs, be sure to check out our companion article, What’s the Difference Between ADLs and IADLs? An OT Perspective.

Now that we’ve covered ADLs and IADLs, here is our detailed list of the various levels of assistance below. You can use these terms to describe the amount of assistance needed in all of the above mentioned basic ADLs and instrumental ADLs.

The Levels of Assistance in Occupational Therapy

You may notice there is a slight variation in terminology used based on different countries and even between OT schools. However, they are all very similar and easy to understand.

Here are the levels of assistance in occupational therapy, ranging from the least amount of assistance to the most:

• Complete independence (independent)
• Modified independence
• Supervision or set up
• Contact guard assist
• Minimal/contact assistance
• Moderate assistance
• Maximal assistance
• Total assistance (dependent)

Let’s go into detail about what all of this actually means, and use the example of showering to facilitate your understanding.

The use of the FIM+FAM outcome measure has guided the majority of the terms used for the levels of assist in the below table. You can find this  outcome measure here. 

Complete independence (Independent) (FIM 7)

A patient can complete an activity alone or with the assistance of assistive devices or modifications.

Ex: Patient mobilizes to the bathroom, they open the shower door independently, they then climb over the step to get in, and they are able to turn the tap on to an appropriate temperature. They can easily open the required shampoo, conditioner, and shower bottle and wash their body and/or hair independently and safely. They are able to identify when their body is clean and dry it independently afterwards.

Modified independence (FIM 6)

Patient can complete an activity independently, but with the use of assistive devices/adaptive equipment, modifications to the environment, or increased time.

Ex: Patient is able to shower independently (as above), but may require use of grab bar in the shower, or shower chair or adapted bottles for squeezing.

Supervision or Set up (FIM 5)

Patient can complete the task without physical assistance, but may require verbal cuing or coaxing, a safe environment or assistive devices, and supervision.

Ex: Patient is able to physically wash their hair and body but requires supervision for safety and verbal cuing to hold onto the grab rail or a reminder that they’ve forgotten to wash a body part.

Contact guard (not in FIM, but commonly used OT terminology)

Patient requires occasional hands on contact to maintain balance.

Ex: OT needs to remain close by in the shower and provide brief hands-on facilitation to prevent loss of balance. Hands hover close to the patient.

Minimal/contact assistance (FIM 4)

Patient requires a small amount of help to be able to complete the activity. OT does 25% or less of the work. (Patient does 75% of the work)

Ex: Patient require assistance to wash under their feet or assistance with opening bottles.

Moderate assistance (FIM 3)

Patient requires some assistance to complete the task. Patient does 50–75% of the work, and OT assists with the remainder.

Ex: OT assists with washing an upper limb and, with a bit of help to transfer onto a shower chair.

Maximal assistance (FIM 2)

Patient requires significant assistance to complete the task. The patient can perform between 25 and 50 percent of the activity, with the remainder performed by the health care practitioner.

Ex: The patient washes his upper body but is unable to wash his lower body and needs significant assistance to transfer onto the shower chair. The patient does, however, still try to contribute toward the task.

Total assistance (Dependent) (FIM 1)

Patient is unable to assist in the task, due to physical or cognitive limitations. The patient may try to assist but complete less than 25% of the task. They are unable to initiate or perform the task.

Ex: patient receives a bed bath, and nurses wash their body. Patient may assist by washing their face.

A Note on Section GG: What OTs in Post-Acute Care Need to Know

If you work or plan to work in a skilled nursing facility, inpatient rehab, LTACH, or home health, you will likely encounter Section GG, and its 6 Point Scale. This is a newer standardized CMS functional assessment that uses slightly different terminology than the traditional FIM-based levels of assistance we described above.

Understanding both systems is important, because the language in Section GG does vary from typical occupational therapy terminology, and Section GG scoring should inform but not change the way you document a client’s performance, establish goals, or create a plan of care (AOTA).

Here is Section GG’s six-level scoring scale, pulled directly from CMS’s Section GG Functional Abilities and Goals page:

06. Independent – Patient/resident safely completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient/resident completes activity. Helper assists
only prior to or following the activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact
guard assistance as patient/resident completes activity. Assistance may be provided throughout the activity or
intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or
limbs, but provides less than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent – Helper does ALL of the effort. Patient/resident does none of the effort to complete the activity.
Or, the assistance of 2 or more helpers is required for the patient/resident to complete the activity.

Note that the activities can be completed with or without an assistive device. You may notice there is no “Modified Independent” to capture the patient’s use of an AD.

For more detailed training on Section GG, AOTA offers resources at aota.org/SectionGG. CMS training is also available online through their website and hopefully through your workplace as well.

So, which types of levels of assist should I use — traditional levels of assist, FIM, or Section GG?

Hopefully this can clear up some confusion up: In acute care and outpatient settings, the traditional levels of assist (independent through total assist) are still the most common documentation language.

In SNFs, inpatient rehab facilities, and home health settings, you will likely be required to score Section GG for CMS reporting purposes (at eval and discharge). The FIM was the standard in inpatient rehab for many years but has largely been replaced by Section GG in post-acute care.

Despite the fact that I am a SNF-based OT and use the GG for evals and discharges, I still use the traditional levels of assist in my daily notes, and my coworkers do the same. 

When in doubt, follow your facility’s documentation guidelines, and use the traditional levels of assist language in your daily notes.

Benefits of using the correct terms for level of assistance:

• Having terminology that all occupational therapists are familiar with. In our careers, we often have to provide carry-over to another OT that is going to be seeing your patient or provide feedback to the multidisciplinary team. It is important that we are all using similar terminology in order to easily understand each other and how much assistance the patient requires.
• Tracking our patient’s progress. Having specific terminology for our patients’ level of assistance allows us to easily track how they are progressing over time.
• The use of the correct terminology will enable us OTs to sound professional in our note-taking and when providing feedback.
• It saves time. Rather than providing a lengthy explanation of how much assistance the patient required in ADL, we can use brief terminology that summarizes the level of assistance required. For more time-saving documentation tips, be sure to check out our other article, Must-Know Occupational Therapy Medical Abbreviations.

Levels of Assist Documentation Examples:

Basic ADL:

Mrs. Smith required moderate assistance for upper body dressing with a t-shirt due to decreased right shoulder flexion and difficulty with the correct orientation of the t-shirt.

Mrs. Smith required minimal assist and minimal verbal cues for side stepping technique and use of grab bars for walk-in shower transfer over 3″ ledge.

Instrumental ADL:

Mrs. Smith made herself a hot beverage while standing with set-up and supervision from the OT to open the jar and kitchen drawer due to decreased hand strength and bilateral coordination.

___________

Wow, that was a lot!

We do hope that you now feel more confident in assessing and documenting the levels of assistance your patient requires.

Please feel free to leave a question or comment below for any further assistance you may need with identifying or describing the level of assistance in ADLs in occupational therapy.

This post was originally published on June 19, 2023 and last updated on March 31, 2026. It was co-authored by Alexia Stavrou, BScOT and Sarah Stromsdorfer, OTR/L.