(a) An occupational therapist shall document the occupational therapistâs evaluation, goals, treatment plan, and summary of treatment in the client record. (b) An occupational therapy assistant shall document the services provided in the client record. (c) Occupational therapists and occupational therapy assistants shall document and sign the client record legibly. (d) Client records shall be maintained for a period of no less than seven years following the discharge of the client, except that the records of unemancipated minors shall be maintained at least one year after the minor has reached the age of 18 years, and not in any case less than seven years.
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