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Q&As
Including Forms and Other Documents in the Record
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…
Practice Tools
Am I a Health Information Custodian or Agent?
Q&As
Record Keeping Considerations for Employers
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…
Q&As
Documentation after leaving employment
Question: Do I need to respond to questions or requests about past clinical records if I have already left my place of employment? Answer: Yes, as regulated health…
eLearning Modules
2024 Annual eLearning Module: Record Keeping – More Than Just a Note
This module is developed by occupational therapists for occupational therapists. The module highlights key record keeping concepts and challenges that occupational therapists face in day-to-day practice. Start the…
Practice Guidance
Guidance: Remote (Virtual) Services, 2024
Practice Guidance
Decision-Making Framework, 2021
Practice Guidance
Guidance: Working Within Managed Resources, 2021
Practice Guidance
Guidance: Working with Third Party Payers, 2024
Practice Tools
Record Keeping Review Tool
Standards
Standard for Record Keeping, 2023
Practice Guidance
Guidance: Private Practice, 2024
Practice Guidance
Guidance: Privacy Legislation and Occupational Therapy Practice, 2023
Webinars & Podcasts
Privacy Legislation and Occupational Therapy Practice Presentation
https://www.youtube.com/watch?v=63zHr5bMSBs&t=37s Watch the College's presentation on the Privacy Legislation and Occupational Therapy Practice guidance document, hosted by the College's Manager of Practice, Sandra Carter and Practice Consultant Diane…
Case Studies
Working with OTAs in a Private Community-Based Practice
Quinn is an occupational therapist and owner of a private practice. She receives referrals mainly from insurers and lawyers for clients after motor vehicle accident or personal injury….
Case Studies
Documenting Group Interventions
Stella works for a community organization providing occupational therapy services in clients’ homes. As part of the organization’s community outreach, they asked her to develop and run group…
Q&As
Occupational therapy billing practices
Occupational therapists are expected to: Engage in fair, equitable and transparent billing practices. Communicate any fees and related information upfront to the client. Follow the requirements set out…
Q&As
Co-signing Occupational Therapist Assistants’ Documentation
Question: Am I required to co-sign the occupational therapist assistant's (OTA) documentation?Answer: No. However, an occupational therapist must review their OTA's documentation as part of the communication and…
Case Studies
Lessons from an In-Home Assessment Complaint
Amanda is an occupational therapist and acts as an independent assessor for an insurance company. She receives a referral to assess for attendant care services in the home…
Q&As
Co-signing provisional occupational therapists’ documentation
Question: Do provisional occupational therapists need their notes co-signed?Answer: No, co-signing of documentation is not required. Although provisional occupational therapists must have a supervisor, provisional occupational therapists are…
Q&As
Frequency of documentation in the clinical record
Question: How often should an occupational therapist be documenting in the clinical record?Answer: It depends. Using clinical judgement is important in determining the frequency of your documentation. How…
Q&As
Appointment Book for Clinical Sessions
Question: Do I have to keep the appointment book that I use to book clinical sessions? Answer: No. If the information is adequately summarized in the clinical record,…
Q&As
Documentation of Deceased Clients
Question: I have been notified that my client has passed away. What are my documentation obligations? Answer: After documenting in the client’s record the date and individual providing…
Case Studies
Changing jobs and responsibly transferring clients
Ally is an occupational therapist who is new to the position of clinic manager. As part of this role, they manage a small interdisciplinary team of health providers….
Q&As
Emailing Client Information
Q: I am working from home, what are the expectations for emailing information that contains client information? A: This is a very important question. Occupational therapists must take…
Case Studies
Electronically Scanning Client Information
Jason is an occupational therapist practicing psychotherapy in a mental health facility. As part of each new session Jason uses standardized paper and pencil screening assessments. Jason often…
Q&As
OTs Completing and Signing Treatment Plans for the Medical Use of Cannabis
In July 2019, the College published a Q & A article about occupational therapists completing and signing treatment plans for the medical use of cannabis. We received many…
Case Studies
Succession planning for client records
Marina is an occupational therapist with a private practice providing psychotherapy treatment to her clients. She works out of her home office and is the health information custodian…
Case Studies
Working within managed resources
Nia is an occupational therapist working on a subacute general medicine floor. On the subacute unit, OT referrals are automatically generated on admission. There are 2 full-time OTs…
Q&As
Commenting and changing reports after resigning as an OT
Q: I have resigned my registration with the College and am no longer practicing as an occupational therapist. I have been asked to testify in court related to…
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