Bus. & Prof. Code 2570.185 (2000)

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.

Bus. & Prof. Code 2570.28(k) (2002; amended by SB 821, 2009)

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.

Bus. & Prof. Code 2570.28(m) (2002; amended by SB 821, 2009)

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.