Standard for Record Keeping, 2023

When entering information into client records, ensure that all information is truthful and accurate. Consider the subtleties of what is being said and what is not being said and how information is phrased. The occupational therapist should be mindful of their own social positions and refrain from comments that contain biases when documenting about clients.

Keep in mind how the information in the records will be received by clients and others who will read it. For example, there is a difference in tone between writing that a client “refused” versus “declined” an element of service.

Keep all parts of records respectful, using professional and culturally sensitive language.

Adopt a documentation process that allows for consistent application of the Standards.

Date and sign every entry.

Indicate the duration or timing of services provided.

Keep records that are accurate and complete, clearly organized, legible, and in English or French.

Explain abbreviations in a note, or refer readers to a list of terms or abbreviations with explanations.

Complete records in a timely manner in accordance with the clinical need and organizational requirements.

At clients’ request or when lawfully required, provide access to their records or to the process for obtaining them.

Retain all data that was used to inform clinical decisions but cannot be included or summarized in the record. Note the location of this data (for example, paper-based standardized assessment forms). When converting data to an electronic format, ensure that the integrity of the data is maintained.

If the information being collected falls under the Personal Health Information Protection Act, 2004:

1. Develop and follow policies and procedures for the management of lock box information
2. If acting as a health information custodian, have a contingency plan for unexpected events to ensure that clients continue to have access to their records.

Document client-identifying information and referral details (for example, source and reason). Confirm client identity and the accuracy of any referral information provided.

Include the initial and ongoing consent of clients or substitute decision-makers.

Record all findings, interventions, reports, and service details. Record client input and input from others (obtained with consent) that has clinical value.

Document relevant clinical information about group therapy in which clients participate (for example, stated goals, client insights, and adverse events). Notes may be made in individual client records or in a group record, such as a file containing a group’s purpose, duration, attendance, and resources provided.

Identify tasks that have been assigned to others (for example, occupational therapy assistants or students), and confirm that client consent was obtained. Include names and titles of the persons assigned if known, or indicate any workplace protocol followed for assignment.

Document information about any controlled acts delegated to the occupational therapist (referencing medical directives or orders, acceptance of the delegation and outcomes).

Include relevant details when services are transferred or ending (for example, client status and input, transfer of accountability, resources provided, and recommendations and referrals).

Apply a signature to each entry after verifying that the information is accurate and complete. The signature must include the author’s designation and either their full name or, if the full name is referenced or easily available, their first initial and last name or their initials.

Take steps to ensure the security of all signatures, including those that are electronic.

Where there are shared and overlapping roles and responsibilities with other professionals and combined reports are created, identify the portion of the report for which the occupational therapist is responsible. If there is no clear delineation, the occupational therapist is accountable for the entire report.

Review the record keeping completed by occupational therapy assistants to confirm that it is accurate and follows appropriate College Standards and workplace policies. Document this review.

When co-signing records completed by students, ensure that all entries and signatures are accurate and complete.

Ensure that any digital devices and paper systems used to create and maintain clinical records have the following features:

1. Access records by client’s name and a unique identifier (such as date of birth)
2. Produce a copy of any record in a timely manner in print or by secure digital means
3. Allow more than one author or contributor to sign, if applicable
4. Maintain an audit trail that records the date of each entry, the identity of the author, and any changes made to the record—while preserving the original content.
5. Protect against unauthorized access
6. Back up digital files and allow for file recovery.

Respond in a timely manner to requests for changes. Clients can request changes to the record verbally or in writing. The occupational therapist has 30 days to respond to the request. They are expected to correct factual errors but need not change a professional opinion.

When a record needs to be changed due to errors, additions, or omissions:

1. Maintain all original entries, or have an audit trail of changes.
2. Identify, date, and sign or initial changes. This is done by the occupational therapist who created the original entry or the person in the organization who is currently responsible for the record.
3. Use an addendum (additional note) to modify a document after distribution. The addendum includes the reason for the changes being made. Send copies of the addendum to everyone who received the original document.

Use controls to securely store records (such as locked filing cabinets, restricted office access, a protocol of logging off devices after use, and secure passwords).

Travel with or transport personal information and personal health information only when it is essential for service delivery. When records and information are in transport, prevent them from being visible to others.

Store paper records securely, and back up all electronic records.

Electronically communicate client information confidentially and securely (for example, using encryption, password protection, de-identification, and secure networks).

Implement physical and technical safeguards to protect the privacy of personal information and personal health information that is disclosed. This includes any financial information collected for the purposes of delivering services. Safeguards may include:

1. Confirming the recipient’s email address or other contact information
2. Periodically auditing and deleting preprogrammed numbers
3. Using transmission receipts or mail tracking
4. Placing a confidentiality statement on outgoing communications, including email, fax, and paper.

Stay informed of workplace policies and procedures for reporting a privacy breach.

If the occupational therapist is responsible for clients’ personal information and personal health information, ensure that policies and procedures are in place for managing and tracking breaches.

If personal information or personal health information has been lost, stolen, released to the wrong persons, or accessed without authorization, make reasonable efforts to notify everyone involved.

Report breaches of confidential client health information as required, either to the employer or to the appropriate privacy commissioner.

Ensure that all records related to billing and payment are clear and include:

1. Full name and designation of the providers of the services or products
2. Full name of the client to whom the services or products were provided
3. Full name and address of any third party to whom fees were charged, if applicable
4. Items sold or services delivered
5. Date of services or purchases
6. Fee for services or products
7. Method of payment
8. Invoice or receipt of payment
9. Any differential fees charged for services (for example, reduced fees)

Store financial information in client records, or note the location where the information is securely stored.

Maintain documents to show that the equipment used to provide occupational therapy services is safe, clean, and well-maintained (for example, sterilization protocols and routine inspection reports).

If not directly responsible for ensuring that equipment has appropriate service records, know where to access these records.

Retain equipment records for a minimum of 5 years from the date of last entry, even if the equipment is discarded.

Know the privacy legislation that applies as well as any organizational or employment policies on record retention and disposal. For records governed by the Personal Health Information Protection Act, 2004:

1. Ensure that records are accessible and maintained for at least 10 years after the date of the last entry. With pediatric records, they must be maintained 10 years after the client reached (or would have reached) 18 years of age.
2. Ensure that records are maintained longer than 10 years if there is reason to believe that the health information will be needed for a valid purpose (for example, a pending legal proceeding).
3. Follow legal requirements for the secure disposal of records.
4. Maintain a list of files that have been disposed, including names and dates. Destroy the list after 10 years unless organizational or practice policy indicates otherwise.