C-26, r. 121 - Regulation respecting the keeping of records and consulting-rooms by a member of the Ordre professionnel des ergothérapeutes du Québec

Updated to 1 September 2012

This document has official status.

chapter C-26, r. 121

Regulation respecting the keeping of records and consulting-rooms by a member of the Ordre professionnel des ergothérapeutes du Québec

Professional Code

(chapter C-26, s. 91).

DIVISION I KEEPING OF RECORDS

1. An occupational therapist shall keep, in accordance with sections 10 and 11, a record for each client at the place where the occupational therapist practises the profession.

O.C. 354-93, s. 1.

2. The occupational therapist’s record shall contain the following items and information:

(1)  the date on which the record is opened;

(2)  where the client is a natural person, the client’s name at birth, sex, birthdate, address and telephone number;

(3)  where the client is a partnership or legal person, the client’s name, the address and telephone number of the client’s establishment and the name, address, telephone number and official title of the authorized representative;

(4)  a summary description of the reasons for the consultation;

(5)  a description and the date of all professional services provided;

(6)  a summary of the conclusions of the evaluation and, where applicable, a description of the occupational therapy treatment plan and recommendations;

(7)  notes on the client’s progress;

(8)  annotations, correspondence and any other documents relating to the professional services provided;

(9)  any document referred to in section 6 relating to the sending of information to the client or third parties, and, in particular, any document signed and dated by the client authorizing such information to be sent;

(10)  a copy of any service contract or a description of any specific agreement concerning the nature and terms of a professional service;

(11)  the signature of the occupational therapist who entered the information prescribed in paragraphs 1 to 10 in the record.

O.C. 354-93, s. 2.

3. An occupational therapist shall keep each person’s record up-to-date until professional services are no longer provided to that person.

O.C. 354-93, s. 3.

4. An occupational therapist shall keep each record for at least 5 years following the date on which the last service was provided.

O.C. 354-93, s. 4.

5. An occupational therapist shall keep all records in a room or cabinet to which the general public does not have access and which can be locked with a key or otherwise so as to ensure the confidentiality of the information contained therein.

O.C. 354-93, s. 5.

6. Where a copy of a document in the client’s record is sent to that client, or where a client asks that such copy or information be sent to a third party, the occupational therapist shall insert a note in the record to that effect, dated and signed by the client in compliance with paragraph 9 of section 2.

O.C. 354-93, s. 6.

7. Without restricting the scope of section 2, no occupational therapist may be required to include in the record all the unprocessed data analyzed and the result of which is written in the record.

O.C. 354-93, s. 7.

8. Upon the expiry of the time period set out in section 4, an occupational therapist may destroy a record provided it is done in such a way that the confidentiality of the information contained in the record is ensured.

O.C. 354-93, s. 8.

9. Nothing in this Regulation shall be interpreted as excluding the use of computers or any other technology for the drawing up and keeping of an occupational therapist’s records, provided that their confidentiality is ensured.

O.C. 354-93, s. 9.

10. Where an occupational therapist practises in an institution within the meaning of the Act respecting health services and social services (chapter S-4.2) or the Act respecting health services and social services for Cree Native persons (chapter S-5), the user’s record within the meaning of those Acts and their regulations is considered, for the purpose of this Regulation, to be the occupational therapist’s record if the occupational therapist can enter, or have entered, the information prescribed in section 2 in the form of a report or otherwise. In such case, sections 4, 5 and 8 do not apply to the occupational therapist.

If an occupational therapist practising in an institution within the meaning of the Act respecting health services and social services or the Act respecting health services and social services for Cree Native persons cannot enter, or have entered, the information prescribed in section 2 in the form of a report or otherwise in the user’s record within the meaning of those Acts and their regulations, the occupational therapist shall keep a separate record for each user.

O.C. 354-93, s. 10.

11. Where an occupational therapist is a member of or is employed in a partnership of occupational therapists, or is employed by a natural or legal person, the occupational therapist may include in the records of such partnership or such employer the information prescribed in section 2 relating to the client to whom services are rendered by the occupational therapist. If the information is not included in the records of the partnership or employer, the occupational therapist shall keep a record for each client.

O.C. 354-93, s. 11.

DIVISION II KEEPING OF CONSULTING-ROOMS

12. An occupational therapist’s consulting-room shall be laid out in such a manner that confidentiality is ensured.

O.C. 354-93, s. 12.

13. An occupational therapist shall set up a waiting room near the consulting-room for the persons who are to receive professional services.

O.C. 354-93, s. 13.

14. An occupational therapist’s permit shall be posted in public view.

O.C. 354-93, s. 14.

15. An occupational therapist who is to be absent from the consulting-room for more than 5 consecutive working days shall take the necessary measures to inform any client who attempts to contact the occupational therapist of the duration of the absence and of the procedure to follow in an emergency.

O.C. 354-93, s. 15.

16. Sections 12 to 15 apply only with respect to a consulting-room where an occupational therapist practises independently, for another occupational therapist or for a partnership of occupational therapists.

O.C. 354-93, s. 16.

17. This Regulation replaces the Regulation respecting the keeping of records and consulting offices by occupational therapists (R.R.Q., 1981, c. C-26, r. 87).

O.C. 354-93, s. 17.

18. (Omitted).

O.C. 354-93, s. 18.

REFERENCES

O.C. 354-93, 1993 G.O. 2, 1964