N.J. Admin. Code § 13:44K-10.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 13:44K-10.1 - Preparation and maintenance of client records

(a) An occupational therapist, or a licensed occupational therapy assistant acting under the supervision of a licensed occupational therapist, shall prepare and maintain for each client a contemporaneous, permanent client record that accurately reflects the client's contact with the occupational therapist or the occupational therapy assistant, whether in an office, hospital or other treatment, evaluation or consultative setting.

(b) 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 client record:

1. 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 client record;

2. The client's name, address and telephone number. The client's name shall appear on each page of the record;

3. The location and dates of all treatments, evaluations or consultations;

4. Findings upon initial evaluation, including the client's relevant history and results of appropriate tests and examinations conducted;

5. 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;

6. Progress notes for each day of treatment. Progress notes shall include, at a minimum, the date the client received treatment, a description of the treatment rendered, the name of the licensee or other person rendering treatment, and notations of the client's status regardless of whether significant changes have occurred since the last date of treatment.

i. 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.

ii. 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, consistent with the provisions of 13:44K-5.3, shall be countersigned by the supervising occupational therapist, notwithstanding the delegation of supervision responsibilities to a licensed occupational therapy assistant pursuant to 13:44K-6.4.

iii. If more than one progress note appears on a page, one signature on the page shall be sufficient to indicate review and approval of all progress notes on the page;

7. Periodic reassessment of the client's status consistent with the goals set forth in the treatment plan;

8. Information regarding referrals to other professionals and any reports and records provided by other professionals;

9. 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

10. Fees charged by the occupational therapist and paid by the client, unless a separate financial record is kept.

(c) A licensed occupational therapist shall periodically review and update the client's plan of care.

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

(e) A licensed occupational therapist, or a licensed occupational therapy assistant acting under the direction of a licensed occupational therapist, shall comply with the provisions of this section notwithstanding an employer's recordkeeping requirements.

(f) A licensed occupational therapist, or a licensed occupational therapy assistant acting under the supervision of a licensed occupational therapist, shall not falsify a patient's record.

N.J. Admin. Code § 13:44K-10.1

Amended by 51 N.J.R. 769(b), effective 5/20/2019