Standards of Practice, Documentation, and Client Care Responsibilities
This domain tests whether you practice in a defensible, client-centered way and whether your records tell the truth about what happened. Questions often hinge on documentation timing, objectivity, and the OT's responsibility to individualize care.
Standards of practice
- Complete an individualized evaluation before intervention, then establish measurable goals and a plan of care.
- Obtain informed consent and involve the client in goal-setting.
- Coordinate with other providers and make referrals when the client's needs exceed OT scope.
- Reassess progress and revise the plan when goals are met, unmet, or the condition changes.
- Plan discharge and provide appropriate transition recommendations.
Documentation
- Record services promptly, accurately, objectively, and legibly, with date, time, signature, and credential.
- Document only what was actually provided. Never chart a service that did not occur.
- Make corrections with a single line, initial, and date so the original entry remains readable; do not obliterate or rewrite.
- Late entries should be labeled as late and dated when written, not backdated to imply contemporaneous recording.
- Record supervision and communication with the OTA when required by the setting or the Board.
Worked example
A therapist forgets to document a treatment session and later adds a note dated the day of service. What is the problem?
Reasoning: Backdating creates a false impression that the note was written at the time of care. The therapist should write a late entry with the actual date of writing, identify it as late, and accurately describe the service. The underlying service may still be documented, but the record must not be falsified.
Traps that cost marks
- Writing subjective conclusions such as "patient did well" without measurable data.
- Omitting the OTA supervision record.
- Altering a prior note instead of making a proper correction.
- Documenting a planned service as if it were delivered.