Record keeping & Documentation Flashcards
Electronically Scanning Client Information
- 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 transferring the data would alter its integrity then it would be better to retain the hard copy, with a notation in the electronic health record, indicating its existence and where it can be found
Client’s access to record
Clients have a right to access the information that providers hold about them. This includes all personal health information regardless of where the information is stored.
OT should make reasonable efforts to inform clients about how they can
access their records including how to contact the information custodian.
Access requests should be responded by the information custodian. OT who are agents of a custodian should ascertain who is in charge of responding to requests (if not the therapists) and take steps to facilitate the forwarding of the request to the appropriate person.
Clients should be provided with copies of records and, where reasonable, assistance with understanding the information.
Generally, access requests should be responded to within 30 days. In practice, a response as soon as possible is advisable.
Access to records should be refused in only limited situations, including if:
- Releasing the records involves a risk of harm to the client or another individual
- The information was provided by a third party in confidence, and the identity of the third party needs to be kept confidential
- The information is subject to legal privilege
- The records are from psychologists and include raw data from standardized psychological tests
- The records include data from standardized tests that is not interpreted or summarized elsewhere in the record.
- was collected as part of an investigation, inspection, or similar
procedure, and the resulting proceedings, appeals, or processes have not yet been concluded
Access to record following Discontinuation of Practice
OT –> develop and implement a plan for how clients will access their records when the occupational therapist is absent or discontinuing practice.
The plan may include secure retention and storage of the documents or transfer of the client records to another person who is legally authorized to hold the records or a successor health information custodian in keeping with the provisions defined in PHIPA.
For third party access to record/referral
for example, independent examinations or expert reports
Obtain consent for the disclosure of assessment results, reports, and intervention plans to third party payers, other professionals, partners, and interested parties unless exceptions to this disclosure apply under privacy legislation
What to document?
- Document client-identifying information (e.g. name and date of birth) and referral details (for example, source and reason)
- 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
- Identify tasks that have been assigned to others (e.g. 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 OT (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).
Manage record changes appropriately
- Respond in a timely manner to requests for changes (30 days to respond)
- Clients can request changes to the record verbally or in writing. Upon receipt of a correction request, the OT who recorded the information shall consider whether the client has demonstrated that the record is inaccurate or incomplete and whether the error or omission affects the purpose for which the information is held. If both conditions are met, the record must be corrected e.g. mistakes, misfiling, fraud, or incomplete information in accordance with College record keeping standards.
If the section of record requested to be corrected reflects a professional opinion or observation made in good faith and the author of the record disagrees with the rationale in the request for correction, the record need not be corrected.
When a record needs to be changed due to errors, additions, or omissions:
- Maintain all original entries, or have an audit trail of changes.
- Identify, date, and sign or initial the 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.
- 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.
Safely store client personal health information
- 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:
**Confirming the recipient’s email address **or other contact information
Periodically auditing and deleting pre-programmed numbers
Using transmission receipts or mail tracking
Placing a confidentiality statement on outgoing communications, including email, fax, and paper.
Manage breaches of confidentiality or privacy securely
- Stay informed of workplace policies and procedures for reporting a privacy breach
- 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.
If a breach occurs, the health information custodian needs to notify the affected individual(s) at the first reasonable opportunity. In addition, the law requires the health information custodian to also notify the individual that they can make a complaint about the breach to the Information and Privacy Commissioner of Ontario.
If you are an agent of a health information custodian (for example, if you are a regulated health professional who works for a group practice, a hospital or for another regulated health professional) you need to tell the responsible custodian about the breach at the first reasonable opportunity.
Properly document financial transactions
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
- Full name of the client to whom the services or products were provided
- Full name and address of any third party to whom fees were charged, if applicable
- Items sold or services delivered
- Date of services or purchases
- Fee for services or products
- Method of payment
- Invoice or receipt of payment
- 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.
Keep equipment records
- Maintain documents to show that the equipment used to provide OT 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.
Follow rules for retaining and disposing of records
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:
- 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.
- 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 (e.g. a pending legal proceeding).
- Follow legal requirements for the secure disposal of records (Destruction of record: cross-shredding / burning; electronic: consult technology specialist)
- make a draft paper during an assessment → finish the documentation → Destroy it/Keep it together with the documentation
- 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.
decision-making tree: document group therapy
What is the purpose or nature of the group? (e.g. treatment vs. education)
What is the ** level of risk** to the client? (e.g. psychotherapy vs. caregiver support)
What is the ** format** of the group? (e.g. drop-in vs. referral)
Will ** another health care provider co-facilitate** ?
What ** information is available** and relevant to include?
Are there any organizational policy requirements?
What are the expectations under the Standard for Record Keeping?
Documenting groups that are co-lead with others
should decide in advance with the other group facilitator(s) how the documentation will be completed (eg. Each provider may choose to document their own notes vs one provider may take responsibility for documenting an interprofessional note)
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
GROUP THERAPY: What to Document?
Scope and Context of Group
1. The type of group (e.g. one-time education session, weekly reoccurring group, drop-in, or registration/referral)
- The goals of the group, including the goals of each session if it is a reoccurring group
- Location and duration of the session(s)
- Attendance (can be documented on a separate sheet if it is an education session, or in each client’s clinical record if recommendations are provided or individual occupational therapy goals are addressed)
- Any unexpected or adverse events that occurred in the group
- Any other information as required by the organization/employer
Assessment and Intervention
7. Any observations by the occupational therapist
- Any individual progress towards goals or any modifications to the goals
- Individual or overall feedback from the participants
- The information that was provided to participants (E.g. handouts, presentations, strategies discussed, or recommendations provided)
How to Document group therapy?
Separate Individual clinical records
For groups where participants receive individual assessment/intervention or have an increased level of risk
1. specific goals for the client
2. progress
3. concerns noted
4. adverse events
5. recommendations
One group note/file
Documenting the collective experience of the group in one note may be sufficient where the risk is low e.g. in drop-in groups where the focus is on providing general education.
1. attendance list
2. handouts/resources
3. high level notes on the overall experience, or summary comments from the group
