Question: Should forms or other documents (for example, standardized assessment forms, funding applications or vendor quotes) be included in the clinical record?
Answer:
As outlined in the College’s Standard for Record Keeping, 2023, occupational therapists are expected to “Record all findings, interventions, reports, and service details. Record client input and input from others (obtained with consent) that has clinical value.”(indicator 3.3).
The standard does not specify every form or document that should go in the record. Occupational therapists should consider what information is clinically relevant, is needed to enable interprofessional collaboration and continuity of care, and what information needs to be kept and retrievable for future purposes (such as for patient/client follow up or legal proceedings).
Occupational therapists are also expected to comply with record keeping policies of their workplace. There may be organizational requirements regarding what specific forms or documents should be in record. There may also be limitations or restrictions on what can be included (for example based on the capabilities of the electronic record keeping system).
The Standard states “Retain all data that was used to inform clinical decisions but cannot be included or summarized in the record. Note the location of this data (for example, paper-based standardized assessment forms). When converting data to an electronic format, ensure that the integrity of the data is maintained.” (indicator 2.8).
The Standard provides flexibility for occupational therapists to either summarize all the relevant information in the record or to include original forms based on their professional judgement and in compliance with organizational requirements.
If summarizing the data, the clinical record at minimum should reflect:
- The type of form, document or application (for example, standardized assessment, equipment funding application, or vendor quote)
- The purpose and clinical relevance of the document (why it supports the client’s care)
- Details of the date completed/submitted, any findings, recommendations and expected outcomes
- What occupational therapy decisions are supported by the document
- Which other partners are involved (vendor, Ministry, other funding organization)
If forms and documents are stored separately from the client’s record, the location of this information should be noted in the record. The health information custodian should know where to access any documents that are stored separately, should there be a future request to access a copy of the record.
If a document cannot be scanned or included due to organizational or technological processes, the occupational therapist is responsible for summarizing the relevant information in the clinical record.
In summary, the College expectation is that all clinically relevant information is documented, detailed and accessible, not that every form or piece of paper must be in the record.