{"id":1310,"date":"2024-11-27T15:08:30","date_gmt":"2024-11-27T20:08:30","guid":{"rendered":"https:\/\/live-coto.pantheonsite.io\/?post_type=resource&#038;p=1310"},"modified":"2025-01-16T09:43:27","modified_gmt":"2025-01-16T14:43:27","slug":"standard-for-record-keeping-2023","status":"publish","type":"resource","link":"https:\/\/www.coto.org\/resources\/standard-for-record-keeping-2023\/","title":{"rendered":"Standard for Record Keeping, 2023"},"content":{"rendered":"\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-standard-for-record-keeping\">\n    <div class=\"section-header \">\n        <h2>Standard for Record Keeping<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<p>Occupational therapists\u2019 records are legal documents intended to officially capture the entirety of occupational therapy services provided. Records document the following:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>How occupational therapists are monitoring client health status<\/li>\n\n\n\n<li>The processes of consent and assessment<\/li>\n\n\n\n<li>Professional analysis and interventions made<\/li>\n\n\n\n<li>Client input, intervention plans, and outcomes<\/li>\n\n\n\n<li>Other clinically significant events<\/li>\n<\/ul>\n\n\n\n<p>Records are a mechanism to communicate health information to clients and other professionals, partners, and interested parties. They enable interprofessional collaboration and continuity of care. Client records demonstrate the provision of safe, ethical, and effective occupational therapy.<\/p>\n\n\n\n<p>In addition to complying with the Standard for Record Keeping, occupational therapists must complete and retain records according to applicable privacy laws and organization-specific policies and procedures.<\/p>\n\n\n\n<p>Clinical and non-clinical occupational therapists have record keeping responsibilities related to the appropriate management of information and effective communication. In non-clinical settings, documentation needs vary for occupational therapists, and only some record keeping indicators may apply.<\/p>\n\n\n\n<p><em>Occupational therapists are expected to:<\/em><\/p>\n\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-1-be-sensitive-to-the-wording-of-notes\">\n    <div class=\"section-header \">\n        <h2>1. Be sensitive to the wording of notes<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>1.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>When entering information into client records, ensure that all information is truthful and accurate. Consider the subtleties of what is being said and what is not being said and how information is phrased. The occupational therapist should be mindful of their own social positions and refrain from comments that contain biases when documenting about clients.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>1.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Keep in mind how the information in the records will be received by clients and others who will read it. For example, there is a difference in tone between writing that a client \u201crefused\u201d versus \u201cdeclined\u201d an element of service.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>1.3<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Keep all parts of records respectful, using professional and culturally sensitive language.<\/p>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-2-attend-to-administrative-requirements\">\n    <div class=\"section-header \">\n        <h2>2. Attend to administrative requirements<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Adopt a documentation process that allows for consistent application of the Standards.<br><\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Date and sign every entry.<br><\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.3<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Indicate the duration or timing of services provided.<br><\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.4<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Keep records that are accurate and complete, clearly organized, legible, and in English or French.<br><\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.5<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Explain abbreviations in a note, or refer readers to a list of terms or abbreviations with explanations.<br><\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.6<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Complete records in a timely manner in accordance with the clinical need and organizational requirements.<br><\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.7<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>At clients\u2019 request or when lawfully required, provide access to their records or to the process for obtaining them.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.8<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>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.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>2.9<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>If the information being collected falls under the Personal Health Information Protection Act, 2004:<\/p>\n\n\n\n<ol style=\"list-style-type:lower-alpha\" class=\"wp-block-list\">\n<li>Develop and follow policies and procedures for the management of lock box information<\/li>\n\n\n\n<li>If acting as a health information custodian, have a contingency plan for unexpected events to ensure that clients continue to have access to their records.<\/li>\n<\/ol>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-3-know-what-details-to-record\">\n    <div class=\"section-header \">\n        <h2>3. Know what details to record<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>3.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Document client-identifying information and referral details (for example, source and reason). Confirm client identity and the accuracy of any referral information provided.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>3.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Include the initial and ongoing consent of clients or substitute decision-makers.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>3.3<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Record all findings, interventions, reports, and service details. Record client input and input from others (obtained with consent) that has clinical value.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>3.4<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Document relevant clinical information about group therapy in which clients participate (for example, stated goals, client insights, and adverse events). Notes may be made in individual client records or in a group record, such as a file containing a group\u2019s purpose, duration, attendance, and resources provided.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>3.5<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Identify tasks that have been assigned to others (for example, occupational therapy assistants or students), and confirm that client consent was obtained. Include names and titles of the persons assigned if known, or indicate any workplace protocol followed for assignment.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>3.6<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Document information about any controlled acts delegated to the occupational therapist (referencing medical directives or orders, acceptance of the delegation and outcomes).<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>3.7<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Include relevant details when services are transferred or ending (for example, client status and input, transfer of accountability, resources provided, and recommendations and referrals).<\/p>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-4-apply-signature-and-designation-correctly\">\n    <div class=\"section-header \">\n        <h2>4. Apply signature and designation correctly<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>4.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Apply a signature to each entry after verifying that the information is accurate and complete. The signature must include the author\u2019s designation and either their full name or, if the full name is referenced or easily available, their first initial and last name or their initials.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>4.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Take steps to ensure the security of all signatures, including those that are electronic.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>4.3<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Where there are shared and overlapping roles and responsibilities with other professionals and combined reports are created, identify the portion of the report for which the occupational therapist is responsible. If there is no clear delineation, the occupational therapist is accountable for the entire report.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>4.4<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Review the record keeping completed by occupational therapy assistants to confirm that it is accurate and follows appropriate College Standards and workplace policies. Document this review.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>4.5<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>When co-signing records completed by students, ensure that all entries and signatures are accurate and complete.<\/p>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-5-use-acceptable-systems\">\n    <div class=\"section-header \">\n        <h2>5. Use acceptable systems<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>5.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Ensure that any digital devices and paper systems used to create and maintain clinical records have the following features:<\/p>\n\n\n\n<ol style=\"list-style-type:lower-alpha\" class=\"wp-block-list\">\n<li>Access records by client\u2019s name and a unique identifier (such as date of birth)<\/li>\n\n\n\n<li>Produce a copy of any record in a timely manner in print or by secure digital means<\/li>\n\n\n\n<li>Allow more than one author or contributor to sign, if applicable<\/li>\n\n\n\n<li>Maintain an audit trail that records the date of each entry, the identity of the author, and any changes made to the record\u2014while preserving the original content.<\/li>\n\n\n\n<li>Protect against unauthorized access<\/li>\n\n\n\n<li>Back up digital files and allow for file recovery.<\/li>\n<\/ol>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-6-manage-record-changes-appropriately\">\n    <div class=\"section-header \">\n        <h2>6. Manage record changes appropriately<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>6.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Respond in a timely manner to requests for changes. Clients can request changes to the record verbally or in writing. The occupational therapist has 30 days to respond to the request. They are expected to correct factual errors but need not change a professional opinion.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>6.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>When a record needs to be changed due to errors, additions, or omissions:<\/p>\n\n\n\n<ol style=\"list-style-type:lower-alpha\" class=\"wp-block-list\">\n<li>Maintain all original entries, or have an audit trail of changes.<\/li>\n\n\n\n<li>Identify, date, and sign or initial changes. This is done by the occupational therapist who created the original entry or the person in the organization who is currently responsible for the record.<\/li>\n\n\n\n<li>Use an addendum (additional note) to modify a document after distribution. The addendum includes the reason for the changes being made. Send copies of the addendum to everyone who received the original document.<\/li>\n<\/ol>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-7-safely-store-client-personal-information-and-personal-health-information\">\n    <div class=\"section-header \">\n        <h2>7. Safely store client personal information and personal health information<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>7.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Use controls to securely store records (such as locked filing cabinets, restricted office access, a protocol of logging off devices after use, and secure passwords).<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>7.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Travel with or transport personal information and personal health information only when it is essential for service delivery. When records and information are in transport, prevent them from being visible to others.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>7.3<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Store paper records securely, and back up all electronic records.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>7.4<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Electronically communicate client information confidentially and securely (for example, using encryption, password protection, de-identification, and secure networks).<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>7.5<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Implement physical and technical safeguards to protect the privacy of personal information and personal health information that is disclosed. This includes any financial information collected for the purposes of delivering services. Safeguards may include:<\/p>\n\n\n\n<ol style=\"list-style-type:lower-alpha\" class=\"wp-block-list\">\n<li>Confirming the recipient\u2019s email address or other contact information<\/li>\n\n\n\n<li>Periodically auditing and deleting preprogrammed numbers<\/li>\n\n\n\n<li>Using transmission receipts or mail tracking<\/li>\n\n\n\n<li>Placing a confidentiality statement on outgoing communications, including email, fax, and paper.<\/li>\n<\/ol>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-8-manage-breaches-of-confidentiality-or-privacy-securely\">\n    <div class=\"section-header \">\n        <h2>8. Manage breaches of confidentiality or privacy securely<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>8.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Stay informed of workplace policies and procedures for reporting a privacy breach.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>8.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>If the occupational therapist is responsible for clients\u2019 personal information and personal health information, ensure that policies and procedures are in place for managing and tracking breaches.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>8.3<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>If personal information or personal health information has been lost, stolen, released to the wrong persons, or accessed without authorization, make reasonable efforts to notify everyone involved.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>8.4<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Report breaches of confidential client health information as required, either to the employer or to the appropriate privacy commissioner.<\/p>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-9-properly-document-financial-transactions\">\n    <div class=\"section-header \">\n        <h2>9. Properly document financial transactions<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>9.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Ensure that all records related to billing and payment are clear and include:<\/p>\n\n\n\n<ol style=\"list-style-type:lower-alpha\" class=\"wp-block-list\">\n<li>Full name and designation of the providers of the services or products<\/li>\n\n\n\n<li>Full name of the client to whom the services or products were provided<\/li>\n\n\n\n<li>Full name and address of any third party to whom fees were charged, if applicable<\/li>\n\n\n\n<li>Items sold or services delivered<\/li>\n\n\n\n<li>Date of services or purchases<\/li>\n\n\n\n<li>Fee for services or products<\/li>\n\n\n\n<li>Method of payment<\/li>\n\n\n\n<li>Invoice or receipt of payment<\/li>\n\n\n\n<li>Any differential fees charged for services (for example, reduced fees)<\/li>\n<\/ol>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>9.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Store financial information in client records, or note the location where the information is securely stored.<\/p>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-10-keep-equipment-records\">\n    <div class=\"section-header \">\n        <h2>10. Keep equipment records<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>10.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Maintain documents to show that the equipment used to provide occupational therapy services is safe, clean, and well-maintained (for example, sterilization protocols and routine inspection reports).<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>10.2<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>If not directly responsible for ensuring that equipment has appropriate service records, know where to access these records.<\/p>\n\n<\/div>\n<\/div>\n\n\n\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>10.3<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Retain equipment records for a minimum of 5 years from the date of last entry, even if the equipment is discarded.<\/p>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-11-follow-rules-for-retaining-and-disposing-of-records\">\n    <div class=\"section-header \">\n        <h2>11. Follow rules for retaining and disposing of records<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<p><strong>Record retention and disposal requirements vary based on the privacy legislation that applies to an occupational therapist&#8217;s practice or services. Records may also include audiovisual, multimedia, and financial records.<\/strong><\/p>\n\n\n\n<div class=\"labeled-list\">\n        <div class=\"labeled-list-inner\">\n\n<div class=\"labeled-list-item\">\n    <div class=\"labeled-list-item-label\">\n        <h3>11.1<\/h3>\n    <\/div>\n    <div class=\"labeled-list-item-inner\">\n\n<p>Know the privacy legislation that applies as well as any organizational or employment policies on record retention and disposal. For records governed by the&nbsp;<em>Personal Health Information Protection Act, 2004<\/em>:<\/p>\n\n\n\n<ol style=\"list-style-type:lower-alpha\" class=\"wp-block-list\">\n<li>Ensure that records are accessible and maintained for at least 10 years after the date of the last entry. With pediatric records, they must be maintained 10 years after the client reached (or would have reached) 18 years of age.<\/li>\n\n\n\n<li>Ensure that records are maintained longer than 10 years if there is reason to believe that the health information will be needed for a valid purpose (for example, a pending legal proceeding).<\/li>\n\n\n\n<li>Follow legal requirements for the secure disposal of records.<\/li>\n\n\n\n<li>Maintain a list of files that have been disposed, including names and dates. Destroy the list after 10 years unless organizational or practice policy indicates otherwise.<\/li>\n<\/ol>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n<\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-related-college-documents\">\n    <div class=\"section-header \">\n        <h2>Related College documents<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<div class=\"resource-grid has-fade-in-up\" role=\"grid\" aria-label=\"Resource Grid\">\n    \n\n<a \n    href=\"https:\/\/www.coto.org\/resources\/standard-for-consent-2023\/\" \n        class=\"resource-link resource-item \" \n    aria-label=\"Standard for Consent, 2023 \"\n>\n    <div class=\"card-header\">\n        <!-- Resource Types -->\n       <div class=\"resource-types\">\n            <div class=\"resource-type-item\">\n                                                            <img loading=\"lazy\" decoding=\"async\" width=\"22\" height=\"24\" src=\"https:\/\/www.coto.org\/wp-content\/uploads\/2024\/12\/Standards.svg\" class=\"attachment-full size-full\" alt=\"Standards Icon\" aria-hidden=\"true\" \/>                                                                <span>Standards<\/span>\n                                                <\/div>\n        <\/div>\n\n        <!-- Resource Languages -->\n                            <div class=\"resource-languages\">\n                                                        <button \n                        class=\"resource-language-item\"\n                        data-language-url=\"https:\/\/www.coto.org\/resources\/standard-for-consent-2023\/normes-de-consentement-2023\/\"\n                        data-external=\"false\"\n                        onclick=\"window.resourceCardHandlers.handleLanguageClick(event, this)\" \n                        aria-label=\"Go to resource in FR - Normes de consentement, 2023\"\n                        title=\"Normes de consentement, 2023\"\n                    >\n                        FR                    <\/button>\n                            <\/div>\n                \n\n        <!-- External Resource Indicator -->\n                <!-- File Resource Indicator -->\n            <\/div>\n\n    <div class=\"card-title\">\n        <!-- Resource Title -->\n        <h3>Standard for Consent, 2023<\/h3>\n    <\/div>\n\n    <!-- Resource Topics -->\n    <!-- <div class=\"card-footer\">\n                    <div class=\"resource-topics\">\n                                    <span class=\"resource-topic-item\">\n                        Competencies &amp; Standards                    <\/span>\n                                    <span class=\"resource-topic-item\">\n                        Consent                    <\/span>\n                            <\/div>\n            <\/div> -->\n\n<\/a>\n\n\n\n\n<script>\n    \/\/ Initialize the global handler object if it doesn't exist\n    if (typeof window.resourceCardHandlers === 'undefined') {\n        window.resourceCardHandlers = {\n            handleLanguageClick: function(event, element) {\n                event.preventDefault();\n                event.stopPropagation();\n                const url = element.getAttribute('data-language-url');\n                const isExternal = element.getAttribute('data-external') === 'true';\n                \n                if (url) {\n                    if (isExternal) {\n                        window.open(url, '_blank', 'noopener,noreferrer');\n                    } else {\n                        window.location.href = url;\n                    }\n                }\n            }\n        };\n    }\n<\/script>\n\n<a \n    href=\"https:\/\/www.coto.org\/resources\/standard-for-the-supervision-of-students-and-occupational-therapy-assistants-2023\/\" \n        class=\"resource-link resource-item \" \n    aria-label=\"Standard for the Supervision of Students and Occupational Therapy Assistants, 2023 \"\n>\n    <div class=\"card-header\">\n        <!-- Resource Types -->\n       <div class=\"resource-types\">\n            <div class=\"resource-type-item\">\n                                                            <img loading=\"lazy\" decoding=\"async\" width=\"22\" height=\"24\" src=\"https:\/\/www.coto.org\/wp-content\/uploads\/2024\/12\/Standards.svg\" class=\"attachment-full size-full\" alt=\"Standards Icon\" aria-hidden=\"true\" \/>                                                                <span>Standards<\/span>\n                                                <\/div>\n        <\/div>\n\n        <!-- Resource Languages -->\n                            <div class=\"resource-languages\">\n                                                        <button \n                        class=\"resource-language-item\"\n                        data-language-url=\"https:\/\/www.coto.org\/resources\/standard-for-the-supervision-of-students-and-occupational-therapy-assistants-2023\/normes-de-supervision-des-etudiants-en-ergotherapie-et-des-aides-ergotherapeutes-2023\/\"\n                        data-external=\"false\"\n                        onclick=\"window.resourceCardHandlers.handleLanguageClick(event, this)\" \n                        aria-label=\"Go to resource in FR - Normes de supervision des \u00e9tudiants en ergoth\u00e9rapie et des aides-ergoth\u00e9rapeutes, 2023\"\n                        title=\"Normes de supervision des \u00e9tudiants en ergoth\u00e9rapie et des aides-ergoth\u00e9rapeutes, 2023\"\n                    >\n                        FR                    <\/button>\n                            <\/div>\n                \n\n        <!-- External Resource Indicator -->\n                <!-- File Resource Indicator -->\n            <\/div>\n\n    <div class=\"card-title\">\n        <!-- Resource Title -->\n        <h3>Standard for the Supervision of Students and Occupational Therapy Assistants, 2023<\/h3>\n    <\/div>\n\n    <!-- Resource Topics -->\n    <!-- <div class=\"card-footer\">\n                    <div class=\"resource-topics\">\n                                    <span class=\"resource-topic-item\">\n                        Competencies &amp; Standards                    <\/span>\n                                    <span class=\"resource-topic-item\">\n                        Supervision                    <\/span>\n                            <\/div>\n            <\/div> -->\n\n<\/a>\n\n\n\n\n<script>\n    \/\/ Initialize the global handler object if it doesn't exist\n    if (typeof window.resourceCardHandlers === 'undefined') {\n        window.resourceCardHandlers = {\n            handleLanguageClick: function(event, element) {\n                event.preventDefault();\n                event.stopPropagation();\n                const url = element.getAttribute('data-language-url');\n                const isExternal = element.getAttribute('data-external') === 'true';\n                \n                if (url) {\n                    if (isExternal) {\n                        window.open(url, '_blank', 'noopener,noreferrer');\n                    } else {\n                        window.location.href = url;\n                    }\n                }\n            }\n        };\n    }\n<\/script><\/div>\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-references\">\n    <div class=\"section-header \">\n        <h2>References<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<p>Personal Health Information Protection Act, 2004, Statutes of Ontario (2004, c. 3, Sched. A). Retrieved from the Government of Ontario website:&nbsp;<a href=\"https:\/\/www.ontario.ca\/laws\/statute\/04p03\">https:\/\/www.ontario.ca\/laws\/statute\/04p03<\/a>&nbsp;&nbsp;<\/p>\n\n<\/div>\n    <\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"template":"","meta":{"_acf_changed":false,"advanced_seo_description":"","jetpack_seo_html_title":"","jetpack_seo_noindex":false,"footnotes":""},"resource-audience":[19,17],"resource-topic":[29,41,33],"resource-type":[13],"class_list":["post-1310","resource","type-resource","status-publish","hentry","resource-audience-employers","resource-audience-registrants","resource-topic-competencies-standards","resource-topic-privacy","resource-topic-record-keeping","resource-type-standards"],"acf":[],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource\/1310","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource"}],"about":[{"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/types\/resource"}],"author":[{"embeddable":true,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/users\/1"}],"version-history":[{"count":7,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource\/1310\/revisions"}],"predecessor-version":[{"id":2120,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource\/1310\/revisions\/2120"}],"wp:attachment":[{"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/media?parent=1310"}],"wp:term":[{"taxonomy":"resource-audience","embeddable":true,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource-audience?post=1310"},{"taxonomy":"resource-topic","embeddable":true,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource-topic?post=1310"},{"taxonomy":"resource-type","embeddable":true,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource-type?post=1310"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}