Recordkeeping

The Rules of the Board of Regents on Unprofessional Conduct require that health professionals complete and maintain accurate records for each patient. These records may include:

  • prescription or referral for treatment
  • documentation of findings from evaluation
  • intervention plan
  • treatment intervention
  • patient response
  • outcomes
  • recommendations

Records must be maintained for six years. For patients ranging in age from birth to 21, records must be maintained for six years and at least one year after the patient/client turns 21.

Access to Patient Records

Occupational therapy professionals and their patients should be aware that under some conditions other individuals might have access to the records. Practitioners should request for patients to sign a release of information waiver prior to transmitting records to other individuals, institutions, or third party payers. Records must be maintained in a manner to assure patient confidentiality. Your records must be accurate, legible, and signed and/or co-signed with appropriate identifying credentials.

Patients have the right to access to their records under most circumstances under Section 18 of the Public Health Law. If you deny a patient access to his/her records, you must inform the patient of his/her right to appeal to the Office of Record Access of the Department of Health.

Electronic Records

Occupational therapy professionals who maintain electronic records should implement a mechanism for safeguarding and maintaining records and confidentiality in the event of an electronic failure.

Disposing of Records

If you dispose of records when there is no obligation or need to maintain them, they must be properly destroyed to safeguard patient confidentiality.

Discontinuing Practice

Occupational therapy professionals who retire or transfer their practice must make provisions for records to be maintained and accessed, if requested. The records of patients may not be included in the sale of a professional practice without the specific, informed consent of the patient. Patient names and other personal information may not be identified in the course of a sale of a practice or in the assessment of the value of a practice.

Occupational therapy professionals should make provisions for the maintenance and destruction of patient records in the event of a therapist's death.

Last Updated: May 28, 2009