Forms, Record Keeping and Accountability

Background

Riya, an occupational therapist (OT), works as an independent contractor in the insurance industry. She provides services to clients after they have sustained work-related injuries or have been involved in workplace accidents. Riya’s role involves meeting with clients to assess the impact of the workplace injuries on their activities of daily living and making appropriate recommendations for workplace modifications and assistive devices. In her role, Riya completes numerous forms for her clients, writes reports to submit to clients’ employers and insurers, and maintains clients’ clinical records. She often recommends devices such as ergonomic chairs, standing desks, and specialized lifting devices and completes applications to submit to the insurer or employer on behalf of her clients. 

Riya is 7 months pregnant and will be going off on maternity leave in 1.5 months. She sees a client, Mrs. Tomley, and recommends a hydraulic height adjustable work station for her after trialling a similar product from the vendor. Riya completes the necessary form and documents her actions in Mrs. Tomley’s clinical record. She is aware that the insurer can take some time to process the form and is worried if they have questions and need to contact her she will be on maternity leave. Riya asks her colleague, Matt if she can transfer the file to him. She explains what she has done thus far, provides the equipment application form that she has completed for the workstation and asks Matt to sign off on it and submit it. Matt, who has not seen the client wonders what he should do.

Considerations

• Matt reviews the form and notes under the location for the ‘Health Professional’s Signature’ that it states: “I hereby certify that I have assessed the applicant named on this form in person”.
  
  
• Matt also reads a statement on the last page of the form stating: “It is an offence to knowingly provide false information to obtain funding for equipment”.
  
  
• Matt reviews the Standards for Record Keeping and contacts the Practice Resource Service at the College to determine his accountabilities when applying his signature.
  
  
• Matt reviews insurer’s policies for equipment applications online and decides to contact the insurer to further understand their policies and procedures. 

Outcome

• After reading the application form and calling the insurer, Matt determines that he is unable to sign off on the form to apply for Mrs. Tomley’s work station. 
  
  
• Matt contacts Riya to explain that he is unable to sign off on the form as he is not the OT who assessed Mrs. Tomley. He states that it is the responsibility and accountability of the OT who completed the assessment to fill out, sign, and submit the form.
  
  
• Matt further explains the implications of him signing off on the form and that it could be considered fraud and professional misconduct as he is not the OT who assessed Mrs. Tomley for the work station.
  
  
• Matt agrees to accept the transfer of the file after Riya has completed and submitted the form and documented her actions in Mrs. Tomley’s clinical record. 
  
  
• Matt encourages Riya to contact the insurer to determine her obligations for follow up on the application prior to going off on maternity leave as she was the Health Professional who submitted the application.     

Discussion

OTs should always review forms (including the “fine print”) to ensure they are aware of the accountabilities and implications associated with signing their name and designation. The Standards for Record Keeping, Standard 4 – Application of Signature, outlines the expectations of OTs when applying their signature. 

OTs who have another designation, for example ADP Authorizer, should be aware of policies, procedures, and relevant legislation that are applicable to that designation. 

The College expects OTs to review their documentation on forms and in client clinical records to ensure the information is complete and accurate prior to applying their signature. It is important for OTs to understand their accountability and obligations as a regulated health professional.    

References

• Standards for Record Keeping
• Essential Competencies of Practice for Occupational Therapists in Canada

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