BACKGROUND

Occupational therapists are often asked by clients and other stakeholders to complete forms and documents as part of the occupational therapy service.

Examples:

  • Melissa is an occupational therapist (OT) who works in the auto-insurance sector. She was approached by a client’s lawyer to complete a Request for Assessment of Capacity under Section 16 Form 4.

  • Alex is an OT working in the home and community care sector. He was asked by a client to complete a T2201 Disability Tax Credit Certificate.

  • Reena is an OT in private practice. She was asked by a client to be a supporting reference on his passport application form.

Before proceeding, OTs should carefully review the entire form and consider the following:


CONSIDERATIONS 

Risks to the client

  • What are the risks and benefits of completing the form? Have you discussed these with the client and obtained consent to proceed? Some forms can have serious implications for a client such as for making decisions about care or finances. OTs need to ensure they are getting client consent to understand the risks and benefits of having the form completed. 

What is the information being asked?

  • Reading the fine print of the form is important. Is the form requesting medical information? Will completing the form involve communicating a diagnosis? OTs need to ensure that when completing forms, they are doing so within the scope of OT practice, have the competencies and knowledge, and are aware of any risks associated with the information provided on the form. Some forms levy a fine if misused, therefore OTs need to ensure they are confident with the information they have assessed and gathered to back up their opinion.

Is there a process?

  • OTs should ensure they are establishing and following a process when reviewing forms and documents. It may require speaking to managers or other colleagues to clarify organizational policies and legislation applicable to the practice setting.

Is the occupational therapist the most appropriate professional to complete the form?

  • Sometimes the OT is the most convenient health professional available because they are seeing the client regularly in the home or community, but this does not mean they are the most appropriate professional. OTs must consider whether another professional would be better suited to speak to the information that is requested on the form. Other professionals could include a family physician, a care coordinator, or a legal representative. If another professional is deemed more appropriate, OTs can help facilitate this process with the client.
  • There may also be professional boundaries to be considered. For example, will providing a personal reference for a client affect the therapeutic relationship moving forward? Are there any policies from the employer or organization that prevents the OT from using their professional contact information for this purpose?

Signing the form

  • Is OT designated as one of the professionals allowed to complete the form? An OT is expected to use and display their title appropriately when signing forms.

OUTCOME

After reviewing their forms, consulting with colleagues and the College’s Practice Resource Service:

  • Melissa determines that OTs and other individuals can complete a Request for Assessment of Capacity under Section 16 Form 4. Melissa was asked by the client’s lawyer to complete the form. She understands there is a potential risk to the client who could be found incapable to manage finances. As Melissa has only had one session with the client, she did not have enough clinical information. She decides to call the lawyer, explain her reasoning and decline completing the form. She suggests others who might be more appropriate such as the family physician or social worker.
  • Alex determines that OTs are listed as one of the health professionals allowed to complete specific sections (walking, feeding, dressing) of the Disability Tax Credit Certificate. Alex had recently attended an educational in-service at his community organization about this and consults his manager to clarify the process. He determines that he has the competency and clinical information to complete the form for the client.

  • Reena reads the passport application form and determines that the reference needs to be an adult who has known the client personally for 2 years or more. It does not require a professional opinion of an OT. Reena has a long-standing therapeutic relationship with the client, and she is concerned about the risk of professional boundaries becoming blurred with providing a personal reference. She decides to work with the client to identify other individuals who may be more appropriate to be listed as a reference.

CONCLUSION

Occupational therapists are frequently asked by clients, families, and other stakeholders to complete forms or documents. It is important for OTs to determine if the services referred to in the form or document are within their professional scope of practice.

OTs must:

  • be able to speak to their clinical reasoning and decision-making related to any form bearing their signature and designation, and
  • follow the College Standards for Practice, including obtaining appropriate client consents and managing any associated risks.

CONTACT

If you have questions about the application of College Standards and resources, contact the Practice Resource Service: 1.800.890.6570/416.214.1177x240 or practice@coto.org.

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