Keeping accurate and timely records is an essential step in ensuring safe and effective patient care. Records serve as the connecting thread between health care providers, clients, and family members. Record keeping is an essential part of the job and
client care.
Record keeping is a part of an occupational therapist’s accountability and part of the employer’s accountability too. Employers care about record keeping and will often conduct random audits to ensure policies and standards
are being met.
See the College's Standard for Record Keeping for more information.
Reporting Obligations: Some employers may decide to terminate employees who are unable to keep up with their record keeping responsibilities. When this occurs, employers are required to report these terminations to the College. Even when
a regulated health professional resigns, if they resigned during an investigation or audit by the employer or during the termination process, the employer must report.
See our page on Mandatory Reports for more information.
Recent trends
Unfortunately, the College has seen an increasing trend of occupational therapists being terminated for a lack of record keeping. Since June 1, 2022, the College has initiated six investigations into employer reports of termination involving unsatisfactory
record keeping.
To put this into perspective, the College has initiated a total of 14 investigations based on employer reports of termination. Nearly half of all these investigations have been about record keeping.
Decisions related to these investigations have ranged from advice and guidance to the ordering of a Specified Continuing Education and Remediation Plan (SCERP), which is posted on the public register.
The committee that makes these decisions will consider a range of risk factors, such as:
- the extent of the missing records,
- the opportunities provided to the registrant, by the employer, to remediate the problem, prior to termination,
- the registrant’s accountability, and
- any prior investigations with the College.
In all its decisions, the Inquiries, Complaints and Reports Committee expresses the importance of record keeping. There is also a desire to work with the registrant to remediate the problem so they can continue to practice safely, ethically,
and competently.
It is important for all registrants to take record keeping seriously. If you are falling behind, be transparent with your employer, create a plan to catch-up, and make time management a priority in your practice.
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