Iowa Admin. Code r. 481-806.2 - Recordkeeping
(1) A licensee
should maintain sufficient, timely, and accurate documentation in patient
records to reflect the services provided, facilitate the delivery of services,
and ensure continuity of services in the future.
(2) A licensee should store records in accordance with
state and federal statutes and regulations governing record retention and with
the guidelines of the licensee's employer or agency, if applicable. If no other
legal provisions govern record retention, a licensee should store patient
records for a minimum of five years after the date of the patient's discharge,
or in the case of a minor, three years after the patient reaches the age of
majority under state law or five years after the date of discharge, whichever
is longer.
(3) Electronic
recordkeeping. The requirements of this rule apply to electronic records as
well as to records kept by any other means. When electronic records are kept,
the licensee shall ensure that a duplicate hard-copy record or a backup,
unalterable electronic record is maintained.
(4) Correction of records.
a.
Hard-copy records. Notations
should be legible, written in ink, and contain no erasures or whiteouts. If
incorrect information is placed in the record, it must be crossed out with a
single nondeleting line and be initialed by the licensee.
b.
Electronic records. If a record is
stored in an electronic format, the record may be amended with a signed
addendum attached to the record.
(5) Confidentiality and transfer of records.
Occupational therapists and occupational therapy assistants shall preserve the
confidentiality of patient records consistent with federal and state
law.
(6) Retirement or
discontinuance of practice. If a licensee is the owner of a practice, the
licensee shall notify in writing all active patients and shall make reasonable
arrangements with those patients to transfer patient records, or copies of
those records, to the succeeding licensee upon knowledge and agreement of the
patient.
(7) Nothing stated in
these rules shall prohibit a licensee from conveying or transferring the
licensee's patient records to another licensed individual who is assuming a
practice, provided that written notice is furnished to all patients.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.