Upcoming Webinars 

Disclaimer

The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Menu
Log in


Log in

North Carolina Occupational Therapy Responsibilities

Responsibilities when Supervising/Delegating

Regardless of the setting in which occupational therapy services are delivered, the occupational therapist and the occupational therapy assistant have the following responsibilities during evaluation, intervention, and outcomes evaluation:

Evaluations

The occupational therapist shall:

  • Direct the evaluation process;
  • Determine the need for services;
  • Define the problems within the domain of occupational therapy that need to be addressed;
  • Determine the client's goals and priorities in collaboration with the occupational therapy assistant and the client or caregiver;
  • Interpret the information provided by the occupational therapy assistant and integrate that information into the evaluation decision-making process;
  • Establish intervention priorities;
  • Determine specific future assessment needs;
  • Determine specific assessment tasks that can be delegated to the occupational therapy assistant; and
  • Initiate and complete the evaluation, interpret the data, and develop the intervention plan in collaboration with the occupational therapy assistant.

Intervention Planning

  • The occupational therapist shall develop the occupational therapy intervention plan. The plan shall be developed collaboratively with the occupational therapy assistant and the client or caregiver; and
  • The occupational therapy assistant may provide input into the intervention plan.

Intervention Implementation

The occupational therapist:

  • Shall implement the occupational therapy intervention;
  • May delegate aspects of the occupational therapy intervention to the occupational therapy assistant depending on the occupational therapy assistant's service competency; and
  • Shall supervise all aspects of intervention delegated to the occupational therapy assistant.

The occupational therapy assistant shall implement delegated aspects of intervention in which the occupational therapy assistant has established service competency; and

Occupational therapists or occupational therapy assistants shall not be subject to disciplinary action by the Board for refusing to delegate or refusing to provide the required training for delegation, if the occupational therapist or occupational therapy assistant determines that delegation may compromise client safety.

Intervention Review

The occupational therapist shall meet with each client who has been assigned to an occupational therapy assistant to further assess the client, evaluate intervention, and, if necessary, to modify the individual's intervention plan. The occupational therapy assistant may be present at this meeting;

The occupational therapist shall determine the need for continuing or discontinuing services; and

The occupational therapy assistant shall contribute to the process of determining continuing or discontinuing services by providing information about the client's response to intervention to assist with the occupational therapist's decision making.

Discharge

  • The occupational therapist shall determine the client's discharge from occupational therapy services; and
  • The occupational therapy assistant shall:
    • Report data for discharge summary; and
    • Formulate discharge or follow-up plans under the supervision of the occupational therapist.

Outcome Evaluation

  • The occupational therapist is responsible for the selection, measurement, and interpretation of outcomes that are related to the client's ability to engage in occupations; and
  • The occupational therapy assistant must be knowledgeable about the client's targeted occupational therapy outcome and provide information relating to outcome achievement

Documentation

The occupational therapy practitioner shall document each evaluation, intervention and discharge plan recognizing the unique requirements of specific practice settings, payors, and service delivery models. Documentation shall include the following elements:

  • Client name or identifiable information;
  • Signature with occupational therapist or occupational therapy assistant designation of the occupational therapy practitioner who performed the service;
  • Date of the evaluation, intervention or discharge plan;
  • Objective and measurable description of contact or intervention and client response; and
  • Length of time of intervention session or evaluation.

Citations

21 NCAC 38.0103

21 NCAC 38.0905


Powered by Wild Apricot Membership Software