Use of a Computer to Prepare Patient Records

A licensee who prepares a patient record maintained solely on a personal or other computer shall use a write-protected program which:

• Contains an internal permanently activated date and time recordation for all entries;
• Automatically prepares a back-up copy of the file; and
• Is designed in such manner that, after the occupational therapist or occupational therapy assistant "signs" by means of a confidential personal code ("CPC"), the entry cannot be changed in any manner.

Patient Identification

An occupational therapist or occupational therapy assistant shall include in the patient record at least two forms of identification; for example, name and record number or any other specific identifying information.

Signatures

An occupational therapist or occupational therapy assistant shall finalize or "sign" the entry by means of a CPC. Where more than one individual is authorized to make entries into the computer file of any patient record, the occupational therapist or occupational therapy assistant responsible for the practice shall assure that each such person obtains a CPC and uses the program in the same manner. All notes made in the patient record by a licensed occupational therapy assistant, temporary licensed occupational therapist, temporary licensed occupational therapy assistant or an occupational therapy student fulfilling the required fieldwork component of his or her educational training, shall be countersigned by the supervising occupational therapist.

An occupational therapist or occupational therapy assistant shall document any addenda or corrections to a patient's record in a separately dated, signed and timed note.