Occupational therapists are required to document evaluation, goals, treatment plan and summary of treatment in the patient record. These records shall be maintained for a minimum of seven years following patient's discharge, except records of a minor shall be maintained at least until one year after the minor.
Unprofessional conduct is defined as falsifying or making grossly incorrect, grossly inconsistent, or unintelligible entries in a medical record for controlled substances or dangerous devices.
The California Board of Occupational Therapy may deny or discipline a licensee for falsifying or making grossly incorrect, grossly inconsistent, or unintelligible entries in a patient or hospital record or any other record.
The California Board of Occupational Therapy may deny or discipline a licensee for failing to maintain confidentiality of patient medical information, except as disclosure is otherwise permitted or required by law.
