Documentation, Informed Consent, and Client Rights
Domain 6: Documentation, informed consent, and client rights
This domain tests the record as the legal account of care and the client's right to decide. Expect questions on consent capacity, refusal, and correcting records.
Core rules
- Document the evaluation, plan of care, goals, interventions, progress, education, and discharge in a timely, objective, and authenticated manner.
- Correct errors with a dated, signed addendum; never obliterate, backdate, or alter another clinician's entry.
- Informed consent requires capacity, disclosure of nature, risks, benefits, alternatives, and the right to refuse. Consent is ongoing and may be withdrawn.
- For a client without capacity, obtain consent from the legal guardian or authorized representative; document the basis. Emergency exceptions are narrow.
- Client rights include privacy, dignity, choice, access to records, and a grievance process.
Worked example
A client with a recent stroke refuses transfer training, saying he fears falling. The OT explains the fall-risk consequences, offers a seated alternative and a gait belt, and documents the refusal and education. The OT does not coerce or omit the refusal from the record. If the client later agrees, a new consent note is appropriate.
Traps
Do not obtain consent from whoever is in the room. Do not document interventions before they occur or copy forward without verification. Do not treat refusal as noncompliance; document the client's reasons and the alternatives offered.