Occupational therapists are responsible for keeping detailed records about their clients’ care. These records are legal documents and are very important for ensuring clients receive safe, ethical, and effective care.
If an occupational therapist (OT) leaves their job suddenly—because of resigning, being let go, or taking an unexpected leave—there may be instances when records are not completed.
Incomplete records can cause problems for clients, the therapist, and the employer. That is why it is important to have a plan to ensure that records are completed and accessible.
Why do complete records matter?
- Legal and professional rules: Incomplete records can lead to legal or professional trouble for the therapist or the organization. Missing information can raise concerns about honesty, safety, and transparency.
- Client safety and ongoing care: Other healthcare providers rely on complete records to determine how to continue care. If records are missing or unclear, treatment could be delayed or harm the client.
- Professional responsibility: OTs are expected to finish their documentation before leaving.
- Risks for the employer: Missing documentation may cause unintended issues, such as complaints, legal proceedings, or harm to the organization’s reputation.
- Increased workload for other staff: If the departing OT’s records are incomplete, other staff may be unable to fill in the gaps without full information and may need to start from the beginning, causing inefficiencies.
Employer considerations
- If the OT gives notice: ideally, it is best if the occupational therapist and the employer can work together to create a plan whereby the OT can finish their records given time to complete the necessary record keeping and ensure there is minimal disruption for the patient/client as possible.
- If communication is difficult: the College expects the OT to take reasonable measures to communicate relevant information to help the employer manage client care and notify clients about the change.
- If communication is not possible: the employer should be prepared to manage requests for ongoing services and documentation, including reviewing the available information and notifying clients about their options for occupational therapy services.
Circumstances may vary when dealing with incomplete record keeping. Not sure how to manage your situation? The College’s Practice Resource Service is here to help.
For practice questions, please get in touch with our Practice Resource Service at 1-800-890-6570 ext. 240 or practice@coto.org.
