The Record Request After a Complaint
An outpatient OT receives a certified letter from the Missouri Division of Professional Registration stating that a complaint has been filed. The complaint alleges that she treated a client for 12 visits after the physician's order expired and that she 'altered' a progress note after the client's family requested records. The letter requests copies of the complete record, a written response, and a list of all clients treated during the dates, due in 20 days. The OT remembers that the order expired for two visits and that after the family called she added a sentence to a progress note without a late-entry notation. Her clinic manager says, 'Just revise the note to show the order was renewed and send the cleaner version; the Board only sees what you send.' The OT has not previously been disciplined.
1. How should the OT respond to the Division's request, including the record and the disputed note?
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She should treat the request as a formal regulatory matter. First, preserve the original record exactly as it is, including metadata and the original progress note. She should not delete, overwrite, or replace the note. Second, she should provide a complete copy of the record within the deadline, keeping a log of what was sent and when. If she believes the note needs clarification, she should add a separately dated addendum that identifies the late entry and explains the correction; she should not silently revise the original. Third, she should prepare a factual written response, or exercise her right to consult counsel before responding. She may ask for a short extension in writing if needed, but she should not ignore the deadline. The manager's instruction to send a 'cleaner version' is an instruction to alter evidence and should not be followed.
2. What are the risks of following the manager's instruction?
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Following the instruction could convert a documentation problem into a fraud and unprofessional-conduct problem. The Division and the Administrative Hearing Commission can consider the original record, the timing of the change, and the explanation. A revised note that makes it appear the order was renewed could support allegations of falsification and could affect billing and reimbursement. The OT's license is hers; a manager cannot authorize her to submit a misleading record. Even if the employer owns the paper or electronic record, the OT remains professionally responsible for entries she makes and for representations she signs. The safer course is to disclose the original, explain the error, and show corrective action. Concealment is usually treated more severely than the underlying lapse.
3. What should she do about the two visits without a valid order?
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She should not create a retroactive order or backdate a renewal. She should notify the billing and compliance staff so the two visits can be reviewed and, if appropriate, not billed or refunded. She should document the sequence accurately: when the order expired, when she discovered it, and what she did. If the client needed continued services, she should obtain a current order before further treatment. She should also review her practice for tracking order expiration. In her response to the Division, she can acknowledge the lapse, describe the corrective steps, and avoid excuses that blame the manager alone. Cooperation and correction are more credible than a perfect-looking record created after the complaint.