The Board requires documentation of each intervention session; in other words, there must be an intervention note for each intervention session provided to the client.  

As stated in §372.1(g)(2) of the OT Rules, “The licensee providing occupational therapy services must document for each intervention session. The documentation must accurately reflect the intervention, decline of intervention, and modalities provided.”

Board regulations include, furthermore, in the Code of Ethics, §374.4 of the OT Rules, that occupational therapy practitioners shall, as per Principle 5.C, “Record and report in an accurate and timely manner and in accordance with applicable regulations all information related to professional or academic documentation and activities.” Missing, inaccurate, or delayed documentation may result in disciplinary action if a complaint is filed. 

Refer to the full OT Act and Rules for further Board regulations regarding documentation.

For information regarding additional requirements or regulations of other entities that may exist, please contact any applicable agencies or legislation, the reimbursement source, etc.