Section 4.03. Standards of practice.

  Occupational therapists and occupational therapy assistants shall adhere to the minimum standards of practice of occupational therapy that have become established in the profession, including but not limited to the following areas:

(1)   Screening.

(a) An occupational therapist, alone or in collaboration with an occupational therapy assistant, when practicing either independently or as a member of a treatment team, shall identify individuals who present deficits or declines in performance of their occupations including occupational performance skills and performance patterns.

(b) Screening methods shall take into consideration the occupational performance contexts relevant to the individual.

(c) Screening methods may include interviews, observations, testing and records review to determine the need for further evaluation and intervention.

(d) The occupational therapist or occupational therapy assistant shall transmit screening results and recommendations to all appropriate persons.

(2)   Referrals. Referrals may be accepted from advanced practice nurses, chiropractors, dentists, optometrists, physical therapists, physicians, physician assistants, podiatrists, psychologists, or other health care professionals.

(3)   Evaluation.

(a) The occupational therapist directs the evaluation process. An occupational therapist alone or in collaboration with the occupational therapy assistant shall prepare an occupational therapy evaluation for each individual referred for occupational therapy services. The occupational therapist interprets the information gathered in the evaluation process.

(b) The evaluation shall consider the individual's medical, vocational, social, educational, family status, and personal and family goals, and shall include an assessment of how performance skills, and performance patterns and their contexts and environments influence the individual's functional abilities and deficits in the performance of their occupations.

(c) Evaluation methods may include observation, interviews, records review, and the use of structured or standardized evaluative tools or techniques.

(d) When standardized evaluation tools are used, the tests shall have normative data for the individual's characteristics. If normative data are not available, the results shall be expressed in a descriptive report. Collected evaluation data shall be analyzed and summarized to indicate the individual's current status.

(e) Evaluation results shall be documented in the individual's record and shall indicate the specific evaluation tools and methods used.

(f) Evaluation results shall be communicated to the referring health care professional, if any, and to the appropriate persons in the facility and community.

(g) If the results of the evaluation indicate areas that require intervention by other health care professionals, the individual shall be appropriately referred or an appropriate consultation shall be requested.

(h) Initial evaluation shall be completed and results documented within the time frames established by the applicable facility, community, regulatory, or funding body.

(4)   Program planning.

(a) The occupational therapist is responsible for the development of the occupational therapy intervention plan. The occupational therapist develops the plan collaboratively with the client, and may include the occupational therapy assistant and team working with the client, including the physician — as indicated.

(b) The program shall be stated in measurable and reasonable terms appropriate to the individual's needs, functional goals and prognosis and shall identify short and long term goals.

(c) The program shall be consistent with current principles and concepts of occupational therapy theory and practice.

(d) In developing the program, the occupational therapist alone or in collaboration with the occupational therapy assistant shall also collaborate, as appropriate, with the individual, family, other health care professionals and community resources; shall select the media, methods, environment, and personnel needed to accomplish the goals; and shall determine the frequency and duration of occupational therapy interventions provided.

(e) The program shall be prepared and documented within the time frames established by the applicable facility, community, regulatory, or funding body.

(5)   Program implementation.

(a) The occupational therapy program shall be implemented according to the program plan previously developed. The occupational therapist may delegate aspects of intervention to the occupational therapy assistant dependent on the occupational therapy assistant's demonstrated and documented service competency.

(b) The individual's occupations, occupational performance, skills, occupational performance patterns, and occupational performance contexts and environments shall be routinely and systematically evaluated and documented.

(c) Program modifications shall be formulated and implemented consistent with the changes in the individual's occupational performance skills, occupational performance patterns and occupational performance contexts and environments.

(d) All aspects of the occupational therapy program shall be routinely and systematically reviewed for effectiveness and efficacy.

(6)   Discontinuation of services.

(a) Occupational therapy services shall be discontinued when the individual has achieved the program goals or has achieved maximum benefit from occupational therapy.

(b) A comparison of the initial and current state of functional abilities and deficits in occupational performance skills, and occupational performance patterns, affecting performance in the individual's occupations shall be made and documented.

(c) A discharge plan shall be prepared, consistent with the interventions provided, the individual's goals, and the expected prognosis. Consideration shall be given to the individual's occupational performance contexts and environments including appropriate community resources for referral, and environmental factors or barriers that may need modification.

(d) Sufficient time shall be allowed for the coordination and effective implementation of the discharge plan.

(e) Recommendations for follow-up or reevaluation shall be documented.

History: CR 02-026 : cr. Register December 2002 No. 564 , eff. 1-1-03; correction in (2) (e) made under s. 13.92 (4) (b) 6. , Stats., Register November 2011 No. 671 ; CR 13-109 : am. (1) (a), (2) (title), (a), (c) to (e), (3) (a), (b), (f), (4) (d), (5) (b), (c), (6) (b), (c) Register September 2014 No. 705 , eff. 10-1-14; CR 15-053 : am. (2) (title), r. (2) (a), am. (2) (b), r. (2) (c) to (e), am. (3) (a), (f) Register August 2016 No. 728 , eff. 9-1-16; renum. (2) (b) to (2) under s. 13.92 (4) (b) 1. , Stats., Register August 2016 No. 728 .