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Record Keeping

This page sets out how Occupational Therapists will maintain records in relation to the children and young people that they work with.

Record keeping, as either an occupational therapy record of part of a multidisciplinary record, is an essential and integral part of care.  The purpose of the records is to give a comprehensive accurate and justifiable account of the care, treatment and support provided or planned for a service user.  The information also supports the use if audit, evidence based clinical practice and improvements in clinical effectiveness through research.

(COT 2000)

Statement 1

A record should be kept of all occupational therapy activity and intervention made with, or on behalf of, the client.

Occupational therapists/occupational therapy services are required to:

  1. Clearly identify the client by name, address and date of birth on all records kept.
  2. Document details of all key people involved in the service user's care, both professionals and family/carers.
  3. Document all referral details, including date and source of referral and reason for referral when given.
  4. Document any relevant social, medical or rehabilitative history.
  5. Document, date and time all assessments made, methods used and resulting outcomes.
  6. Document and date the views and wishes of the client about goals or treatment plans, and any timeframes suggested.
  7. Document the consent and nature of consent given to intervention.
  8. Document, date and time all interventions planned and carried out in connection with the client, and the resulting outcomes.
  9. Document and date all reviews, and alterations to goals, treatment plans or timeframes.
  10. Document all interventions or decisions made by members of the multi-disciplinary team when it impacts upon the occupational therapy care given, including decisions taken in clinical supervision.
  11. Incorporate in the records all correspondence, telephone conversations and reports related to the client's care.
  12. Document and date interventions or contact with family and carers, and any outcomes.
  13. Document all information and advice provided to the service user and their family/carers
  14. Document all discharge, closure or transfer details.
  15. Document the destination of onward referrals or care transfers and any information that needs to be considered in handover (with the knowledge and consent of the client).
  16. (College of Occupational Therapists 2000c)

Statement 2

Occupational therapy records should be well organised, well managed and clear; to ensure that they are accessible to those who may need to refer to them.

Occupational therapists/occupational therapy services are required to:

  1. Maintain and organise records systematically, ensuring that they are easy to find and in good order.
  2. Ensure that records are chronological and contemporaneous.
  3. Ensure the records are complete, factual, objective and concise.
  4. Ensure the records are legible and do not use slang or unexplained abbreviations and acronyms.
  5. Amend written records by scoring out with a single line, so that the original text is still legible.
  6. Provide a clear signature, designation and date with all entries, additions or amendments.
  7. Countersign student or support staff records to ensure and demonstrate their accuracy.
  8. Ensure that electronic records clearly identify the member of staff making the record, in the absence of a signature and meet the same standards as written records.
  9. Ensure electronic records are completed to the same standard as written records.

Statement 3

Occupational therapy staff should be aware of, and abide by, legal regulations about the confidentiality, storage and disposal of records, and a client's right to access their own records.  They should also be guided by local policy on these matters.

Occupational therapists/occupational therapy services are required to:

  1. Inform themselves of, and abide by, the key principles of Data Protection Act 1998 and States of Guernsey Council Policies, in relation to a client's right of access to their records. (Great Britain, Parliament 1998a)
  2. Inform themselves of, and abide by, the key principles of the Data Protection Act 1998 and States of Guernsey Council Policies, relating to the confidentiality, storage and disposal of records, (Great Britain, Parliament 1998a)
  3. Store records securely, with arrangements in place to protect them from use by unauthorised persons, damage or loss.
  4. Ensure the safekeeping of other records such as diaries that may be used as legal evidence.
  5. Retain and dispose of records according to legal and Guernsey Council guidance.

Case Notes procedure

TaskProcessAppendixForm (location)Send to:Notes/Contact info
Initial visit - a new case (not open to other team member)Initial Assessment Record should be completed if not done so by referrer4.1*Multi Agency Initial Assessment Record for Children in Need and their Families Cabinet in main officeAdmin to input on PARISCheck correct 'Framework for Assessment' procedure with (SW) Manager.
Care Plan (where OT sole worker)If OT is sole worker on case and/or care manager, care plan must be completed4.2*Care Plan CH7Main office and/or front team office NB Where significant services and/or social care support identified following assessment refer back to SW team for allocation to SW/CCW
Continuation notesShould be completed with date and signature for each contact/intervention (including non-direct eg. telephone calls, ordering of equipment for child)4.3*Record of Contacts CH4 Copy in OT shells so can be completed on screen and print out for notes.
ReviewsShould be completed prior to closure of case and/or at agreed intervals if OT is care manager (ie 6 - 12 months) (Formal review by OT CH11 not necessary if another team member is care manager (ie 6 - 12 months) (Formal review by OT CH11 not necessary if another team member is care manager4.4*Case Worker's Report to Review CH11Admin to input on PARIS & circulate as appropriate to client and MDT 
'Tracking' Assessment processForm P1 should be completed to track child from waiting list, when allocated to OT and when case closed. Complete appropriate section of form in conjunction with service manager Children's Service Assessment Process Record Form P1Input on PARIS 
Occupational therapists/occupational therapy services are required to:
  1. Inform themselves of, and abide by, the key principles of Data Protection Act 1998 and Guernsey Council policy, in relation to a client's right of access to their records. (Great Britain, Parliament 1998a)
  2. Inform themselves of, and abide by, the key principles of the Data Protection Act 1998 and States of Guernsey Council Policies, relating to the confidentiality, storage and disposal of records, (Great Britain, Parliament 1998a)
  3. Store records securely, with arrangements in place to protect them from use by unauthorised persons, damage or loss.
  4. Ensure the safekeeping of other records such as diaries that may be used as legal evidence.
  5. Retain and dispose of records according to legal and Guernsey Council guidance.