(a) An occupational therapist shall document his or her evaluation, goals, treatment plan, and summary of treatment in the patient record.
(b) An occupational therapy assistant shall document the services provided in the patient record.
(c) Occupational therapists and occupational therapy assistants shall document and sign the patient record legibly.
(d) Patient records shall be maintained for a period of no less than seven years following the discharge of the patient, except that the records of unemancipated minors shall be maintained at least one year after the minor has reached the age of 18 years, and not in any case less than seven years.
(Amended by Stats. 2009, Ch. 308, Sec. 31. (SB 819) Effective January 1, 2010.)
Last modified: October 25, 2018