Managing Client Information

COTBC Managing Client Information (MCI) Practice Standards

Please note that this latest revision was adjusted to reflect the October 2, 2017 changes to our bylaws.

Statement of Purpose

These practice standards clarify the occupational therapist’s accountability and the College’s expectations respecting the occupational therapist’s management of client information.  They are designed to assist the occupational therapist to identify and reduce the risks inherent in managing client information, thereby protecting clients from harm.

Managing client information requires compliance with legislation and the legal requirements as set out in the COTBC Bylaws. The College’s focus is on the quality and content of the information contained in the occupational therapy record, as well as on how the occupational therapist collects, records, protects and ensures access to client information. The College acknowledges that different occupational therapists perform these tasks in different ways within different practice contexts and settings.

Managing client information is important because of the many ways in which the occupational therapy record is used. It is a legal document and source of evidence that can demonstrate compliance with the standards of the profession as well as with other standards, laws, and ethical considerations.

The occupational therapy record:
Describes the occupational therapy process
Because the occupational therapist collects and records client information to plan, implement, and carry out a systematic, client-centred care plan, the occupational therapy process must be reflected in the occupational therapy record. Collecting, recording, protecting, and ensuring access to client information can allow the occupational therapist to demonstrate that safe, ethical, and competent care was delivered to the client. The record can also make explicit the therapist’s critical thinking, reasoning, and decision-making.

Facilitates client participation
The client can expect involvement in collecting and recording information that becomes part of the occupational therapy record and can be assured that the privacy of client information is maintained in accordance with all applicable legislation. The client’s right to access current, legible, accurate and complete records of occupational therapy services within statutory limits will be facilitated.  The occupational therapy record will be retained and when no longer required, will be properly destroyed. The management of client information also aids the
occupational therapist to communicate effectively with the client, the primary caregivers, and the family.

Advances quality occupational therapy services
The management of client information aids the occupational therapist to communicate effectively with other health professionals involved in the care of the client. Client information may be used to advance the profession’s evidence and knowledge base through education and research activities. It can also be used by administrators, planners, and the College for decision-making, quality improvement activities, and reflection on practice.

MCI Practice Standard #1: Collecting and Recording Client Information

Principle Statement:
The occupational therapist will ensure that an accurate record of occupational therapy services is created and includes receipt of referral, informed client consent, assessment, intervention, discharge, and follow up.

Practice Expectations
The occupational therapist will ensure that the following information is collected and is part of the occupational therapy record:

  1. Contact information for the source of the client’s referral, including self-referral.
  2. Reason for the referral.
  3. Confirmation that client consent was obtained.
  4. Confirmation of the accuracy and currency of the information provided about the client on the referral.
  5. Client’s full name, address, date of birth, and unique identifier (if applicable).
  6. Client information that is necessary and pertinent to the purpose of the occupational therapy assessment and intervention.

Principle Statement:
The occupational therapist is responsible for the content of the client record related to occupational therapy services and will ensure that the content accurately reflects the occupational therapy services provided.

Practice Expectations
The occupational therapist will include the following information on the client record:

  1. Consent as obtained, dated, and maintained.
  2. Occupational therapy assessments including the assessment procedures results obtained, and conclusion or professional opinion regarding the client’s status.
  3. Documentation of the occupational therapy intervention plan, formulated in collaboration with the client.
  4. Clear reference to any specific care pathway or similar assessment and intervention plan.
  5. Progress notes indicating the outcome of an intervention, changes in the client’s condition, problem formulation, or the intervention plan and goals.
  6. Name, designation, and supervision plan when the occupational therapist assigns a component of the intervention plan (e.g., to students or support personnel)
  7. Cancelled or missed appointments.
  8. Discharge information, which may include the client’s status at discharge, reason for discharge, summary of outcome attained, recommendations such as home program, referral, and an explanatory note when interventions initiated were not completed.

Principle Statement:
The occupational therapist will ensure that records are legible, understandable, complete, and prepared and maintained in a timely and systematic manner.

Practice Expectations
The occupational therapist will ensure the following:

    1. Records are organized in a logical and systematic fashion to facilitate retrieval and information use.
    2. Documentation is completed in a timely manner appropriate to the client and clinical situation.
    3. All documents identify the client and the client’s unique identifier, such as date of birth, record number, or claim number. It must be possible to identify the client in any part of the record.
    4. The date of each professional encounter of any kind with the client, regardless of the medium (email, fax, telephone, or in person), is recorded.
    5. If email has been used by the occupational therapist to make decisions, sufficient detail is documented and retained as part of the record (electronic or paper). This may include the need to print or scan a document to have it preserved.
    6. The date of the receipt and disclosure of client information is recorded.
    7. Abbreviations, acronyms, and diagrams used in the client record have a supporting reference available for those who access the records, to ensure consistency of interpretation.
    8. Every entry is dated and signed and includes the name of the person who made the entry. The signature includes the occupational therapist’s full name and designation. Electronic signatures are protected and linked to a user ID and password.
    9. The occupational therapist who contributes to a combined disciplinary notes or reports, identifies the portion of the note or report for which he or she is responsible and accountable.
    10. When two occupational therapists contribute to the same record, the signature of each is included. The record clearly indicates the author of each entry and who provided the services.
    11. Copies of a record distributed without an original signature by the occupational therapist clearly indicate where the original signed record is located.
    12. Drafts of documents if kept are retained as part of the record and released upon request. Draft notes may be destroyed if not needed, but if they exist at the time that access is sought to the record, they are considered a legal part of the client’s record.
    13. The record may be created and maintained in a computer system if it has the following characteristics:
      • Provides a visual display of the recorded information.
      • Provides a means of access to the record of each client by the client’s full name and a unique identifier, and the record can be validated by confirming additional reliable key indicators such as date of birth.
      • Provides a means to view and print recorded information promptly and in chronological order for each client.
      • Allows more than one author or contributor to sign or attest.
      • Maintains an audit trail which
        1. records the date and time of each entry of information for each client;
        2. indicates the identity of the person who made the entry;
        3. indicates any changes in the recorded information; and
        4. preserves the original content of the recorded information when changed or updated.
      • Provides reasonable protection against unauthorized access. All systems will have user ID and password protection with mechanisms to prevent unauthorized changes to documents (e.g., document locking, readonly access, firewalls, encryption, password).
      • Automatically backs up files at reasonable intervals and allows the recovery of backed-up files or provides reasonable protection against loss of, damage to, and inaccessibility of information. A process is in place to reliably provide recorded information if due to unforeseen or scheduled downtimes of the system, the electronic record is not available.

MCI Practice Standard #2: Protecting Client Information
(Privacy and Security)

Principle Statements:
The occupational therapist will take measures to ensure client confidentiality and the security of client information in order to prevent unauthorized access.

The occupational therapist has a responsibility to understand and apply the legislation that applies to his or her practice and determine personal roles and responsibilities within the context of the practice.
The occupational therapist is expected to consult the relevant legislation, provincial and federal, to determine his or her role in this context (FOIPPA, PIPA, E-Health Act, Privacy Act, PIPEDA).

Practice Expectations
The occupational therapist will do the following:

      1. Develop protocols for storage, access, retention, and destruction of client records in keeping with all applicable legislation and COTBC Bylaws.
      2. Store all occupational therapy records in locked filing cabinets and ensure password-protected computer access.
      3. When travelling, limit the amount and visibility of client information being transported (on paper or portable electronic devices).
      4. Place a notice at the bottom of all emails and fax transmissions regarding confidentiality and procedures if the information is sent to the wrong address or phone line inadvertently.
      5. Obtain client consent regarding what information can be communicated by email.
      6. Ensure that client information to be delivered by mail is sealed, addressed accurately, and marked “confidential.”
      7. Make reasonable efforts to notify the individual involved if his or her information has been lost or stolen, or accessed without his or her authorization.

MCI Practice Standard #3: Client Access to the Occupational Therapy Record

Principle Statement:
The occupational therapist will know and understand legislative obligations and organizational policies and procedures respecting client records so as to be able to help the client access his or her occupational therapy information.

Practice Expectations
The occupational therapist will do the following:

      1. Respond within 30 days to requests by the client or a legally authorized representative for access to the client’s occupational therapy record.
      2. If organizational policies do not exist or are insufficient, develop policies or protocols for client access to occupational therapy records in accordance with legislation, COTBC Bylaws, and other published COTBC documents.
      3. Not agree to contractual provisions which are inconsistent with his or her statutory obligations (e.g., requests by organizations to restrict client access to information).
      4. Provide an opportunity for the client to review and correct personal information in response to any concerns that it is not complete or accurate.
      5. The client may request corrections to his or her occupational therapy records, but does not have the right to demand that the correction be made. If the occupational therapist does not agree that there is an error or omission, he or she must record the client’s request for the correction in the record.
      6. Charge only a reasonable fee to cover the costs of copying and, where appropriate, staff time in retrieving and reproducing the requested record.
      7. Take reasonable measures to ensure the preservation, security, and ongoing access to client occupational therapy records in the event that the agency or organization in which the occupational therapist is employed ceases to operate.

MCI Practice Standard #4: Disclosing the Occupational Therapy Record

Principle Statements:
The occupational therapist will know and understand legislative obligations and organizational policies and procedures about making and releasing copies of client occupational therapy information.

The occupational therapist will respond to requests by stakeholders for access to and or copies of personal information in accordance with legislative obligations.
The occupational therapist will transfer, share, or disclose personal information only with the express consent of the client unless otherwise permitted to do so by law.

Practice Expectations

      1. If organizational policies do not exist or are insufficient, the occupational therapist will develop policies or protocols for stakeholder access to occupational therapy records in accordance with legislation, COTBC Bylaws, and other published COTBC documents.
      2. The occupational therapist may disclose personal information under only those conditions outlined in COTBC Bylaw 78(1–2) and other relevant legislation.
      3. The occupational therapist may refuse to provide copies from a client record or a portion of the client record under those conditions outlined in COTBC Bylaw 86(3) or other legislation (FOIPPA, PIPA) where a reason for refusal applies.
      4. With client consent, the occupational therapist will allow another health professional external to the occupational therapist’s employment organization or agency to examine the client’s clinical record. The occupational therapist will also give a health professional any information from the record and which that professional is legally entitled to receive.
      5. Where the client directs that part of the information be withheld, the occupational therapist will respect that request. If it is deemed reasonably necessary to disclose the withheld information for the provision of or to assist in the provision of health care to the client, the recipient must be notified that part of the information has been withheld.
      6. The occupational therapist will record what information has been released to the client or others and when, and will inform these individuals of the use and disclosure of the client information.
      7. The occupational therapist may charge a reasonable fee to cover costs for photocopying and, where appropriate, staff time in retrieving and reproducing the document (COTBC Bylaw, 86[5]).

MCI Practice Standard #5: Records Respecting Financial Matters

Principle Statements:
The occupational therapist will ensure that a financial record is kept for every client to whom a fee is charged by the occupational therapist.

Financial records may be kept separate from clinical records, and may provide a way to track services offered on an ongoing basis.

Practice Expectations
The occupational therapist’s financial records will do the following:

      1. Identify the client to whom the service or product was provided.
      2. Identify the person(s) who provided the product or service, the job title(s), and the fee of each provider.
      3. Give a description of the service or item sold, a cost of the item or service, and the date provided.
      4. Identify the date and method of payment received.
      5. Provide an accurate fee schedule for the services rendered.
      6. Identify the reason a fee may have been reduced or waived.
      7. Where the fees were charged to a third party, provide the full name and address of the third party.
      8. Identify any balance owing.
      9. Provide information that documents the retention of a collection agency.

MCI Practice Standard #6: Retention and Destruction of the Occupational Therapy Record

If the occupational therapist is the primary record keeper, he or she will establish a process for the retention and destruction of records that ensures that regardless of the medium used, records are maintained for the required period of time and destroyed in accordance with legislative retention and destruction requirements.
If the occupational therapist is not the primary record keeper, he or she will ensure that the record is maintained and that he or she will have access to it during the minimum retention period, and be knowledgeable about the organization’s policies and procedures for occupational therapy record retention and destruction.

Practice Expectations
The occupational therapist will ensure the following:

    1. A client record is retained safely and securely stored for at least 16 years from the date of the last entry in the record or in the case of a minor, the date 16 years after the day on which the client reached or would have reached 19 years old, whichever is later.
    2. The record is maintained after the 16-year period if the occupational therapist reasonably knows that a piece of health information will be required after this time for a valid reason (e.g., ongoing care, legal proceeding).
    3. Prior to the occupational therapist’s resignation, cancellation, or suspension of registration with COTBC, the client retains the right to access his or her record. The occupational therapist will do one of the following:
      • Maintain the client record for at a minimum the retention period defined in this practice standard or any other relevant statute or regulation, and notify the client at the last known address that the occupational therapist intends to resign or is no longer able to provide occupational therapy services, and provide information on how the client can obtain copies of the record; or
      • Transfer the records to either another person who is legally authorized to hold the records, or a successor in keeping with the provisions defined in privacy legislation (FOIPPA, PIPA, and COTBC Bylaws 80–84); and when transferring the record, make reasonable efforts to notify the client at the last known address before transferring the record, or as soon as possible after transferring the record.
    4. Destruction of electronic and paper records is done in a secure manner that prevents anyone from accessing, discovering, or otherwise obtaining the information (e.g., cross-shredding, incinerating, erasing, or destroying files from personal computers and servers).
    5. A list of names and dates for those records that have been destroyed is maintained in perpetuity or until no longer necessary in accordance with statutory requirements.