Why You Should Request Access to Your Occupational Therapy Notes

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Occupational therapists strive to have a plan of care centered on your needs and goals. We believe that the most effective treatments involve partnering with our patients.

An under-utilized way of forming this partnership is encouraging occupational therapy consumers to view the documentation your occupational therapist is recording.

For insurance reimbursement and to maintain our ethical standards, your therapist is thoroughly documenting every encounter that they have with you. This documentation then becomes part of your medical record, and whether you are being seen in a clinic, hospital, or receiving home health care, this information is protected by federal mandate from being view unnecessarily by outside parties.

But, in almost all cases, you should have access to your health information. You may have to jump a few hurdles to get it, but the effort may well be worth it if access increases the effectiveness of your treatment.

A Brief Overview of Your Rights

Since 1996, patients have had the right to view their medical records. Your hospital, doctor, (and therapy clinic) must provide you access to requested segments within 30 days of the request.

Since access to your medical record was legislated as a right, there have been multiple complaints of barriers to accessing these documents, so in January 2016, the Obama administration issued new guidelines to increase the ease of access.

You will still have to check with your specific clinic for how they want you to go about requesting documents and details such as whether they can issue them electronically and if you need to pay for copies. Every clinic should meet the minimum standards set by the federal government.

How You Can Benefit From Accessing Your OT Record

Viewing your health records can enhance any medical treatment you receive. Below are some specific was that accessing your notes can enhance your occupational therapy treatment.

Check the Accuracy of Your Information: Checking for accuracy is a simple first step in reviewing your record. Your therapy may not be as effective as possible if your therapist is working with faulty information. An important place to check for accuracy is your evaluation. Your OT will record an overview of pertinent health information and your current situation. Is your history accurate? Did your therapist miss something that you believe to be relevant to your situation?

Understand Your Goals and Treatment Plan: Your therapist should be clearly communicating your goals and treatment plan with you. If this isn’t happening to any extent, you may not be with the right OT. More likely, though, your therapist is explaining these, but as a consumer, it can be difficult to retain all of the information in a session. Or perhaps your therapist did not thoroughly explain her plan as she does in her documentation. Either way, it can be helpful as a patient to sit down with a written version of your goals and treatment plan. In an evaluation, you should find your goals, a time frame for achieving them, and strategies for getting there.

Understand Your Progress: Each note following the evaluation should relate back to your goals and the progress you are making toward them. Often these goals are broken down into long-term and short-term goals. There are typically 3-5 goal areas that your therapist is working toward. They should be measurable and meaningful to you. Again, your therapist should be verbally updating you on your progress, but it can be helpful to spend some time with a written record so you can be self-monitoring your progress.

Have Documentation Handy for Future Health Care Providers: This last area may not impact your current course of treatment, but can be extremely useful for future therapy you receive. We recommend asking for a copy of your notes when your treatment is complete, especially if there is a chance you will need occupational therapy again in the future for a related condition, such as in the case of chronic conditions.

You can then bring in these old occupational therapy notes whenever you start a new episode of care. Having access to past records allows your therapist to jump-start your treatment, by gaining a better understanding of the course of your condition, what has worked in the past and what hasn’t. Some institutions will automatically issue you a discharge summary, which will neatly summarize your visit. If you don’t receive one, don’t be afraid to ask for one.

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