1. (a) Medical Conditions.

   1. (1) Occupational therapists may evaluate the patient/client to determine the need for occupational therapy services without a referral.
   2. (2) Intervention for a medical condition by an occupational therapy practitioner requires a referral from a licensed referral source.
   3. (3) The referral may be an oral or signed written order. The occupational therapy practitioner must ensure that all oral orders are followed with a signed written order.
   4. (4) If a written referral signed by the referral source is not received by the third treatment or within two weeks from the receipt of the oral referral, whichever is later, the therapist must have documented evidence of attempt(s) to contact the referral source for the written referral (e.g., registered letter, fax, certified letter, email, return receipt, etc.). The therapist must exercise professional judgment to determine cessation or continuation of treatment with a receipt of the written referral.

2. (b) Non-Medical Conditions.

   1. (1) Consultation, monitored services, and evaluation for need of services may be provided without a referral.
   2. (2) Non-medical conditions do not require a referral. However, a referral must be requested at any time during the evaluation or treatment process when necessary to insure the safety and welfare of the consumer.
3. (c) Screening. A screening may be performed by an occupational therapy practitioner.

4. (d) Evaluation.

   1. (1) Only an occupational therapist may perform the evaluation.
   2. (2) An occupational therapy plan of care must be based on an occupational therapy evaluation.
   3. (3) The occupational therapist must have face-to-face, real time interaction with the patient or client during the evaluation process.
   4. (4) The occupational therapist may delegate to an occupational therapy assistant or temporary licensee the collection of data for the assessment. The occupational therapist is responsible for the accuracy of the data collected by the assistant.

5. (e) Plan of Care.

   1. (1) Only an occupational therapist may initiate, develop, modify or complete an occupational therapy plan of care. It is a violation of the OT Practice Act for an occupational therapy assistant to dictate, or attempt to dictate, when occupational therapy services should or should not be provided, the nature and frequency of services that are provided, when the patient should be discharged, or any other aspect of the provision of occupational therapy as set out in the OT Act and Rules.
   2. (2) The occupational therapist and an occupational therapy assistant may work jointly to revise the short-term goals, but the final determination resides with the occupational therapist. Revisions to the plan of care and goals must be documented by the occupational therapist and/or occupational therapy assistant to reflect revisions at the time of the change.
   3. (3) An occupational therapy plan of care may be integrated into an interdisciplinary plan of care, but the occupational therapy goals or objectives must be easily identifiable in the plan of care.
   4. (4) Only occupational therapy practitioners may implement the written plan of care once it is completed by the occupational therapist
   5. (5) Only the occupational therapy practitioner may train non-licensed personnel or family members to carry out specific tasks that support the occupational therapy plan of care.
   6. (6) The occupational therapist is responsible for determining whether intervention is needed and if a referral is required for occupational therapy intervention.
   7. (7) The occupational therapy practitioners must have face-to-face, real time interaction with the patient or client during the intervention process.
   8. (8) Except where otherwise restricted by rule, the supervising occupational therapist may only delegate to an occupational therapy assistant or temporary licensee tasks that they both agree are within the competency level of that occupational therapy assistant or temporary licensee.

6. (f) Documentation.

   1. (1) The patient's/client's records include the medical referral, if required; and the plan of care. The plan of care includes the initial examination and evaluation; the goals and any updates or change of the goals; the documentation of each intervention session by the OT or OTA providing the service; progress notes, any re-evaluations, if required; any written communication and the discharge documentation.
   2. (2) The licensee providing occupational therapy services must document for each intervention session. The documentation must accurately reflect the intervention, decline of intervention, and/or modalities provided.
   3. (3) The occupational therapy assistant must include the name of his or her available supervising occupational therapist in each intervention note. If there is not a current supervising occupational therapist, the occupational therapy assistant cannot intervene.

7. (g) Discharge.

   1. (1) Only an occupational therapist has the authority to discharge patients from occupational therapy services. The discharge is based on whether the patient or client has achieved predetermined goals, has achieved maximum benefit from occupational therapy services; or when other circumstances warrant discontinuation of occupational therapy services.
   2. (2) The occupational therapist must review any information from the occupational therapy assistant(s), determine if goals were met or not, complete and sign the discharge documentation and/or make recommendations for any further needs of the patient in another continuum of care.

Source Note:The provisions of this §372.1 adopted to be effective October 11, 1994, 19 TexReg 7717; amended to be effective August 31, 1995, 20 TexReg 6337; amended to be effective May 8, 1996, 21 TexReg 3716; amended to be effective November 4, 1997, 22 TexReg 10752; amended to be effective October 25, 1998, 23 TexReg 10912; amended to be effective August 21, 2000, 25 TexReg 8063; amended to be effective July 22, 2001, 26 TexReg 5442; amended to be effective July 22, 2002, 27 TexReg 6546; amended to be effective February 27, 2005, 30 TexReg 910; amended to be effective December 4, 2005, 30 TexReg 7892; amended to be effective February 25, 2008, 33 TexReg 1604;amended to be effective September 7, 2009, 34 TexReg 6124; amened to be effective January 9, 2012, 37 TexReg 69.