C-26, r. 121 - Regulation respecting the keeping of records and consulting-rooms by a member of the Ordre professionnel des ergothérapeutes du Québec

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2. The occupational therapist’s record shall contain the following items and information:
(1)  the date on which the record is opened;
(2)  where the client is a natural person, the client’s name at birth, sex, birthdate, address and telephone number;
(3)  where the client is a partnership or legal person, the client’s name, the address and telephone number of the client’s establishment and the name, address, telephone number and official title of the authorized representative;
(4)  a summary description of the reasons for the consultation;
(5)  a description and the date of all professional services provided;
(6)  a summary of the conclusions of the evaluation and, where applicable, a description of the occupational therapy treatment plan and recommendations;
(7)  notes on the client’s progress;
(8)  annotations, correspondence and any other documents relating to the professional services provided;
(9)  any document referred to in section 6 relating to the sending of information to the client or third parties, and, in particular, any document signed and dated by the client authorizing such information to be sent;
(10)  a copy of any service contract or a description of any specific agreement concerning the nature and terms of a professional service;
(11)  the signature of the occupational therapist who entered the information prescribed in paragraphs 1 to 10 in the record.
O.C. 354-93, s. 2.