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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.

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Use of a Computer to Prepare Patient Records

A licensee who prepares a patient record maintained solely on a personal or other computer shall use a write-protected program which:

    • Contains an internal permanently activated date and time recordation for all entries;
    • Automatically prepares a back-up copy of the file; and
    • Is designed in such manner that, after the occupational therapist or occupational therapy assistant "signs" by means of a confidential personal code ("CPC"), the entry cannot be changed in any manner.

Patient Identification

An occupational therapist or occupational therapy assistant shall include in the patient record at least two forms of identification; for example, name and record number or any other specific identifying information.

Signatures

An occupational therapist or occupational therapy assistant shall finalize or "sign" the entry by means of a CPC. Where more than one individual is authorized to make entries into the computer file of any patient record, the occupational therapist or occupational therapy assistant responsible for the practice shall assure that each such person obtains a CPC and uses the program in the same manner. All notes made in the patient record 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.

An occupational therapist or occupational therapy assistant shall document any addenda or corrections to a patient's record in a separately dated, signed and timed note.


Citation

N.J.A.C. ยง 13:44K-10.2


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