21 NCAC 38 .0905             DELINEATION OF CLINICAL RESPONSIBILITIES

Regardless of the setting in which occupational therapy services are delivered, the occupational therapist and the occupational therapy assistant shall have the following responsibilities during client evaluation, intervention, and outcome evaluation:

(1)           Evaluations:

(a)           The occupational therapist shall;

(i)            Direct the evaluation process;

(ii)           Determine the need for services;

(iii)          Define the problems within the domain of occupational therapy that need to be addressed;

(iv)          Determine the client's goals and priorities in collaboration with the occupational therapy assistant and the client or caregiver;

(v)           Interpret the information provided by the occupational therapy assistant and integrate that information into the evaluation decision-making process;

(vi)          Establish intervention priorities;

(vii)         Determine specific future assessment needs;

(viii)        Determine specific assessment tasks that can be delegated to the occupational therapy assistant; and

(ix)          Initiate and complete the evaluation, interpret the data, and develop the intervention plan in collaboration with the occupational therapy assistant.

(b)           The occupational therapy assistant may contribute to the evaluation process by implementing assessments delegated by the occupational therapist.

(2)           Intervention Planning:

(a)           The occupational therapist shall develop the occupational therapy intervention plan. The plan may be developed collaboratively with the occupational therapy assistant and the client or caregiver; and

(b)           The occupational therapy assistant may provide input into the intervention plan.

(3)           Intervention implementation:

(a)           The occupational therapist:

(i)            Shall implement the occupational therapy intervention;

(ii)           May delegate aspects of the occupational therapy intervention to the occupational therapy assistant; and

(iii)          Shall supervise all aspects of intervention delegated to the occupational therapy assistant.

(b)           The occupational therapy assistant shall implement delegated aspects of intervention in which the occupational therapy assistant has established service competency; and

(c)           Occupational therapists shall not be subject to disciplinary action by the Board for refusing to delegate or refusing to provide the required training for delegation, if the occupational therapist determines that delegation may compromise client safety.

(4)           Intervention review:

(a)           The occupational therapist shall meet with each client who has been assigned to an occupational therapy assistant to further assess the client, to evaluate intervention, and, if necessary, to modify the individual's intervention plan;

(b)           The occupational therapist shall determine the need for continuing or discontinuing services; and

(c)           The occupational therapy assistant may contribute to the process of determining continuing or discontinuing services by providing information about the client's response to intervention to assist with the occupational therapist's decision making.

(5)           Documentation:

(a)           The occupational therapy practitioner shall document each evaluation, intervention, and discharge plan recognizing the requirements of practice settings, payors, and service delivery models. Documentation shall include the following elements:

(i)            Client name or identifiable information;

(ii)           Signature with occupational therapist or occupational therapy assistant designation of the occupational therapy practitioner who performed the service;

(iii)          Date of the evaluation, intervention, or discharge plan;

(iv)          Objective and measurable description of contact or intervention and client response; and

(v)           Length of time of intervention session or evaluation.

(b)           The occupational therapist shall determine the overall completion of the evaluation, intervention, or discharge plan; and

(c)           The occupational therapy assistant shall;

(i)            Document intervention, intervention response, and outcome; and

(ii)           Document client's level of function at discharge.

(6)           Discharge:

(a)           The occupational therapist shall determine the client's discharge from occupational therapy services; and

(b)           The occupational therapy assistant shall:

(i)            Report data for discharge summary; and

(ii)           Formulate discharge or follow-up plans under the supervision of the occupational therapist.

(7)           Outcome evaluation:

(a)           The occupational therapist is responsible for the selection, measurement, and interpretation of outcomes that are related to the client's ability to engage in occupations; and

(b)           The occupational therapy assistant must be knowledgeable about duties delegated by the occupational therapist that relate to the client's targeted occupational therapy outcome and provide information relating to outcome achievement.

History Note:        Authority G.S. 90-270.69;

Eff. July 1, 2007;

Amended Eff. December 1, 2009;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016;

Amended Eff. July 1, 2018.