It is an integral part of regulated members’ practice, and an important tool that occupational therapists use to ensure high-quality client care.
The Standards of Practice of the Alberta College of Occupational Therapists, 2003 sets the standards for practice of occupational therapy in Alberta. Documentation is addressed throughout the standards, specifically:
2.1 Document the request for occupational therapy services.
2.5 Discuss and document the terms of agreement for the services to be provided.
2.6 Document the occupational performance issues arising from the process of identifying, validating, and prioritizing these issues with the client.
2.8 Document the screening results and recommendations along with the client’s consent to and agreement with the services offered or lack of consent or agreement.
4.4 Document the assessment results within a predetermined time frame. These results should include the assessment methods used and indicate the performance components and environmental elements to be targeted.
5.4 Document the action plan and describe desired outcomes; indicators of attainment of desired outcomes; type, nature, and methods of intervention; time frame; and evaluation process. The documentation shall be completed within a predetermined time frame, known to the client or appropriate parties.
6.3 Document changes in and factors limiting:
- the client’s response to the intervention
- the client’s goals
- the client’s satisfaction with the process and outcomes
- occupational performance
- performance components
- evaluation elements
6.4 Document the services provided, and the frequency of these services, within a predetermined time frame. 7.4 Document the outcomes of the occupational therapy process and when appropriate, communicate with key participants (e.g., past, present and future service providers, referral source).
8.3 Demonstrate an acceptance of the principles of client-centred practice, including active listening to the client.
8.4 Demonstrate the ability to both convey and receive verbal, nonverbal, and written messages in an effective manner, and address breakdowns in the communication process.
9.2 Demonstrate safe work practices by identifying potential risks and minimizing those risks in the practice setting.
9.4 Demonstrate application of the findings of the evaluation to the subsequent service provided to clients and to his/her practice.
If a complaint is received by the College regarding your practice, the above standards will be used to judge your professional conduct.
The client record is a legal document and source of evidence, the primary purpose of which is to officially record events, decisions, interventions, and plans. Records also act as a communication tool to aid in ensuring continuity of care that assists health care professionals in providing care as well as managing and tracking a client’s health care, services and outcomes. Records are used to communicate information to clients and stakeholders, and can be used to promote interprofessional collaboration. Records facilitate appropriate client care and enhance client safety.
Appropriate records demonstrate professional accountability by documenting service through the continuum of care, from receipt of the referral, through the discussions related to consent for assessment and treatment decisions, as well as goals, plans, and outcomes of care. Records reflect the occupational therapist’s professional analysis and/or opinion, interventions, and recommendations. Records should reflect information provided by the client and communication between the occupational therapist and the client.
Differences in how client healthcare records are kept exist across the multiple settings in which occupational therapists practice, and each client care population has its own unique characteristics and expectations. Still, the foundational principles of documentation apply to every type of documentation in every practice setting.
If in a private practice, a regulated member should establish record retention and disposal processes that ensure records are properly retained and disposed of. At a minimum these processes should:
- ensure compliance with minimum recommended retention period of ten (10) years after the last date of service provided to the client. In the case of minors, client records should be retained for ten (10) years or two (2) years past the age of majority, whichever is longer.
- ensure storage of records protects against threat or hazard to the security or integrity of the health information or of loss of the health information.
- ensure the proper disposal of records to prevent any access, use or disclosure of the health information following its disposal.