Code of Massachusetts Regulations
259 CMR - BOARD OF REGISTRATION OF ALLIED HEALTH PROFESSIONALS
Title 259 CMR 3.00 - Occupational therapists
Section 3.03 - Documentation
Current through Register 1531, September 27, 2024
Timely and accurate documentation is necessary whenever occupational therapy services are provided, regardless of payer source. The Client's record must be signed with the provider's name, professional designation, and license number.
(1) The occupational therapist's primary role in documentation is to ensure that documentation is completed timely, following formats and standards established by the practice setting, agencies, external accreditation programs, state and federal law, and other regulators and payers. The occupational therapist's primary role is to document the following, with input from the occupational therapy assistant, as applicable:
(2) The occupational therapy assistant's primary role is to document the following:
(3) The Occupational Therapy Aide's primary role is to document objective information, such as number of repetitions performed, etc., on documents such as logs and flow sheets.