California CodesBusiness and Professions Code - BPCDivision 2 — Healing ArtsChapter 5.6 — Occupational TherapySection 2570.18.5
(a) An occupational therapist shall document the occupational therapist’s evaluation, goals, treatment plan, and summary of treatment in the client record.
(b) An occupational therapy assistant shall document the services provided in the client record.
(c) Occupational therapists and occupational therapy assistants shall document and sign the client record legibly.
(d) Client records shall be maintained for a period of no less than seven years following the discharge of the client, except that the records of unemancipated minors shall be maintained at least one year after the minor has reached the age of 18 years, and not in any case less than seven years.
Notes
Requires occupational therapists to document evaluation, goals, treatment plans, and treatment summaries, and occupational therapy assistants to document services provided; both must legibly sign client records. Requires records to be kept at least seven years after discharge, except unemancipated minors' records must remain at least one year after age 18 and never less than seven years.
Use as reference
Lexinter.net | California Code, Business and Professions Code - BPC § 2570.18.5 | https://laws.lexinter.net/codes/california/business-and-professions-code/division-2/chapter-5-6/section-2570-18-5