(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.

Terms Used In California Business and Professions Code 2570.18.5

  • Occupational therapist: means an individual who meets the minimum education requirements specified in Section 2570. See California Business and Professions Code 2570.2
  • Occupational therapy: means the therapeutic use of purposeful and meaningful goal-directed activities (occupations) with individuals, groups, populations, or organizations, to support participation, performance, and function in roles and situations in home, school, workplace, community, and other settings. See California Business and Professions Code 2570.2
  • Occupational therapy assistant: means an individual who is licensed pursuant to the provisions of this chapter, who is in good standing as determined by the board, and based thereon, who is qualified to assist in the practice of occupational therapy under this chapter, and who works under the appropriate supervision of a licensed occupational therapist. See California Business and Professions Code 2570.2

(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.

(Added by renumbering Section 2570.185 by Stats. 2022, Ch. 290, Sec. 2. (AB 2671) Effective January 1, 2023.)

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