The Levels of Assistance in Occupational Therapy: What to Know

At the beginning of your journey into occupational therapy, 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’ll highlight the different levels of assistance we use in occupational therapy. Let’s start at the beginning:

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

Instrumental ADLs (IADLs)

• Financial management
• Housework
• Shopping and meal preparation
• Health management
• Managing transportation

A detailed list of the various levels of assistance is provided 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 or schools of training. 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
• Minimal/contact assistance
• Moderate assistance
• Maximal assistance
• Total assistance (dependent)

Let’s go into detail about what 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 commonly used 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 thereafter.

Modified independence (FIM 6)

Patient can complete an activity independently, but with the use of assistive devices, 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.

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.

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

___________

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

Please feel free to email us for any further assistance you may require in identifying or describing the level of assistance in ADLs in occupational therapy.