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Texas Occupational Therapy Documentation 

What must be included in the client record?

The client's records include the medical referral, if required, and the plan of care. The plan of care includes the initial evaluation; the goals and any updates or change of the goals; the documentation of each intervention session by the OT or OTA providing the service; progress notes and any re-evaluations, if required; any patient related documents; and the discharge or discontinuation of occupational therapy services documentation.

What are the OT’s responsibilities when performing the evaluation?

Evaluation--The process of planning, obtaining, documenting and interpreting data necessary for intervention. This process is focused on finding out what the client wants and needs to do and on identifying those factors that act as supports or barriers to performance.

    • Only an occupational therapist may perform an initial evaluation or any reevaluations.
    • An occupational therapy plan of care must be based on an occupational therapy evaluation.
    • The occupational therapist is responsible for determining whether any aspect of the evaluation may be conducted via telehealth or must be conducted in person.
    • The occupational therapist must have contact with the client during the evaluation via telehealth using synchronous audiovisual technology or in person. Other telecommunications or information technology may be used to aid in the evaluation but may not be the primary means of contact or communication.
    • The occupational therapist may delegate to an occupational therapy assistant or temporary licensee the collection of data for the evaluation. The occupational therapist is responsible for the accuracy of the data collected by the assistant.

What are the OT’s responsibilities when creating the Plan of Care?

Occupational Therapy Plan of Care--A written statement of the planned course of Occupational Therapy intervention for a client. It must include goals, objectives and/or strategies, recommended frequency and duration, and may also include methodologies and/or recommended activities.

    • Only an occupational therapist may initiate, develop, modify or complete an occupational therapy plan of care. It is a violation of the OT Practice Act for anyone other than the occupational therapist to dictate, or attempt to dictate, when occupational therapy services should or should not be provided, the nature and frequency of services that are provided, when the client should be discharged, or any other aspect of the provision of occupational therapy as set out in the OT Act and Rules.
    • Modifications to the plan of care must be documented.
    • An occupational therapy plan of care may be integrated into an interdisciplinary plan of care, but the occupational therapy goals or objectives must be easily identifiable in the plan of care.
    • Only occupational therapy practitioners may implement the written plan of care once it is completed by the occupational therapist.
    •  Only the occupational therapy practitioner may train non-licensed personnel or family members to carry out specific tasks that support the occupational therapy plan of care.
    • The occupational therapist is responsible for determining whether intervention is needed and if a referral is required for occupational therapy intervention.

What are the OT’s responsibilities when performing an intervention?

Intervention--The process of planning and implementing specific strategies based on the client's desired outcome, evaluation data and evidence, to effect change in the client's occupational performance leading to engagement in occupation to support participation.

The licensee providing occupational therapy services must document for each intervention session. The documentation must accurately reflect the intervention, decline of intervention, and/or modalities provided.

Who is responsible for the discharge or discontinuation of OT services?

Only an occupational therapist has the authority to discharge clients from occupational therapy services. The discharge or discontinuation of occupational therapy services is based on whether the client has achieved predetermined goals, has achieved maximum benefit from occupational therapy services, or when other circumstances warrant discontinuation of occupational therapy services.

The occupational therapist must review any information from the occupational therapy assistant(s), determine if goals were met or not, complete and sign the discharge or discontinuation of occupational therapy services documentation, and/or make recommendations for any further needs of the client in another continuum of care.

What are the assistant’s documentation responsibilities?

New Regulation: June 1, 2019

In each intervention note, the occupational therapy assistant must include the name of an occupational therapist who is readily available to answer questions about the client's intervention at the time of the provision of services. The occupational therapist in the intervention note may be different from the occupational therapist who wrote the plan of care. The occupational therapy assistant may not provide services unless this requirement is met.

Citation

Tex. Admin. Code §372.1

Tex. Admin. Code §362.1

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