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Contents of the Record

Contents of the Patient Record

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 patient record:

  • 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 patient record;
  • The patient's name, address and telephone number. The patient's name shall appear on each page of the record;
  • The location and dates of all treatments, evaluations or consultations;
  • Findings upon initial evaluation, including the patient's relevant history and results of appropriate tests and examinations conducted;
  • 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;
  • Progress notes for each day of treatment. Progress notes shall include, at a minimum, the date the patient received treatment, a description of the treatment rendered, the name of the licensee or other person rendering treatment, and notations of the patient's status regardless of whether significant changes have occurred since the last date of treatment.
    • 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.
    • 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, shall be countersigned by the supervising occupational therapist, notwithstanding the delegation of supervision responsibilities to a licensed occupational therapy assistant.
    • If more than one progress note appears on a page, s one signature on the page shall be sufficient to indicate review and approval of all progress notes on the page;
  • Periodic reassessment of the patient's status consistent with the goals set forth in the treatment plan;
  • Information regarding referrals to other professionals and any reports and records provided by other professionals;
  • 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 Fees charged by the occupational therapist and paid by the patient, unless a separate financial record is kept.

A licensed occupational therapist shall periodically review and update the patient's plan of care.

Retention

The permanent patient record of occupational therapy services shall be retained for at least seven (7) years from the date of the last entry, unless otherwise provided by law, or in the case of a patient 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 patient reaches the age of 18, whichever is later.

Citation

N.J.A.C. ยง 13:44K-10.1

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