Current through Register Vol. 56, No. 18, September 16, 2024
(a) An
occupational therapist, or a licensed occupational therapy assistant acting
under the supervision of a licensed occupational therapist, shall prepare and
maintain for each client a contemporaneous, permanent client record that
accurately reflects the client's contact with the occupational therapist or the
occupational therapy assistant, whether in an office, hospital or other
treatment, evaluation or consultative setting.
(b) An occupational therapist, or an
occupational therapy assistant, acting under the supervision of an occupational
therapist, shall include at least the following information in the client
record:
1. The full name, as it appears on the
license, of the licensee who rendered care, identification of licensure status
as either an occupational therapist or occupational therapy assistant, license
number and designated supervisor, if applicable. This information shall be
legible and shall appear at least once on each page of the client
record;
2. The client's name,
address and telephone number. The client's name shall appear on each page of
the record;
3. The location and
dates of all treatments, evaluations or consultations;
4. Findings upon initial evaluation,
including the client's relevant history and results of appropriate tests and
examinations conducted;
5. A plan
of care establishing measurable goals of the treatment program, including the
type of treatment to be rendered and the frequency and expected duration of the
treatment;
6. Progress notes for
each day of treatment. Progress notes shall include, at a minimum, the date the
client received treatment, a description of the treatment rendered, the name of
the licensee or other person rendering treatment, and notations of the client's
status regardless of whether significant changes have occurred since the last
date of treatment.
i. An occupational
therapist may dictate progress or session notes for later transcription
provided the transcription is dated and identified as preliminary pending the
occupational therapist's final review and approval.
ii. All progress notes that are created by a
licensed occupational therapy assistant, temporary licensed occupational
therapist, temporary licensed occupational therapy assistant or an occupational
therapy student fulfilling the required fieldwork component of his or her
educational training, consistent with the provisions of
13:44K-5.3, shall be countersigned
by the supervising occupational therapist, notwithstanding the delegation of
supervision responsibilities to a licensed occupational therapy assistant
pursuant to
13:44K-6.4.
iii. If more than one progress note appears
on a page, one signature on the page shall be sufficient to indicate review and
approval of all progress notes on the page;
7. Periodic reassessment of the client's
status consistent with the goals set forth in the treatment plan;
8. Information regarding referrals to other
professionals and any reports and records provided by other
professionals;
9. A discharge
summary which includes the reason for discharge from and outcome of
occupational therapy services relevant to established goals at the time of
discharge; and
10. Fees charged by
the occupational therapist and paid by the client, unless a separate financial
record is kept.
(c) A
licensed occupational therapist shall periodically review and update the
client's plan of care.
(d) The
permanent client record of occupational therapy services shall be retained for
at least seven years from the date of the last entry, unless otherwise provided
by law, or in the case of a client who is a minor at the time of the last date
of treatment, the licensee shall retain the record for seven years from the
last treatment or for at least two years after the minor client reaches the age
of 18, whichever is later.
(e) A
licensed occupational therapist, or a licensed occupational therapy assistant
acting under the direction of a licensed occupational therapist, shall comply
with the provisions of this section notwithstanding an employer's recordkeeping
requirements.
(f) A licensed
occupational therapist, or a licensed occupational therapy assistant acting
under the supervision of a licensed occupational therapist, shall not falsify a
patient's record.
