(A) An occupational therapist:

(1) has the ultimate responsibility for occupational therapy treatment outcomes and for all occupational therapy services performed under the therapist's supervision;

(2) at a minimum, shall provide supervision as required by this chapter;

(3) shall communicate regularly with a supervisee regarding assignments, plan of care, and any changes in the client's status and shall document this communication;

(4) shall reevaluate a client where therapy has been significantly interrupted before reassigning an occupational therapy assistant to the case;

(5) only shall assign to a supervisee those duties and responsibilities for which the supervisee has been trained specifically and for which the supervisee is qualified to perform;

(6) must be accessible to supervisee each working day;

(7) shall perform the initial evaluation of and establish the treatment plan for each client;

(8) shall make a consultation/reassessment visit every seven treatments or thirty days, whichever comes first.

(B) An occupational therapist is responsible for the occupational therapy record of a client. The occupational therapy record shall consist of:

(1) the initial evaluation including a written report signed and dated by the occupational therapist performing the evaluation;

(2) a plan of care, including:

(a) treatment to be rendered;

(b) frequency and duration of treatment;

(c) measurable goals.

Progress notes must be signed and dated by the person rendering treatment. When progress notes are written by an occupational therapy student or an occupational therapy assistant student or examination candidate, the notes are to be countersigned and dated by the occupational therapist or occupational therapy assistant who is providing supervision.

A discharge note containing a statement of the client's status at the last treatment session must be written, signed, and dated by the occupational therapist or occupational therapy assistant rendering services. In the case of the occupational therapy assistant, the occupational therapist must co-sign and consult on all discharge notes.

HISTORY: 1998 Act No. 356, Section 1.