Record Keeping on the Right Side of the Line
Clinical Update January 2015
By Zur Institute
Proper record keeping helps the clinician with treatment, enhances the quality of care, helps maintain a continuity of care, can protect the clinician in cases of board investigations, lawsuit or subpoenas, and helps in the event of the therapist’s retirement, disability, death or other impediment to continuing treatment. The standard of care, HIPAA, and licensing boards all come into play with regard to good clinical records and related best practices.
The Digital Age introduced a new set of complexities in regard to security of digital records on our computers, laptops, smart phones and the cloud. HIPAA solidified patients’ right to access their records in a timely fashion.
Rather than facing licensing board sanctions for inappropriate recording of a psychotherapy session, or for inappropriate storage or disposal of records…
Rather than letting your clinical records with sensitive information fall into the wrong hands…
Rather than being surprised that your digital records on your computer, laptop, cell phone or the cloud are easily accessed by hackers or unauthorized people…
Rather than being caught off guard upon receiving a subpoena and unwittingly compromising your client’s confidentiality by responding inappropriately…
Did you know?
- Keeping adequate records is not only helpful to therapists, but is necessary to comply with the standard of care.
- Like voice messages and phone conversations, if texts or e-mails have clinical significance, they should be noted in the clinical records.
- Never alter records.
- In California, psychologists must keep records for adult clients for seven years and MFTs and LCSWs must keep records for adult clients for ten years. Find out the record retention laws in your state.
- Third party payers do not necessarily have the right to complete access to clinical records.
- Responding to a subpoena appropriately means more than simply handing over records or ignoring it altogether.
- It is sometimes acceptable to provide a summary of clinical records rather than the entire records in response to a subpoena.
- Clinical records must include Office Policies, Informed Consent, Biographical Information, DX or Focus of Treatment, Treatment Plan, Testing, ongoing clinical notes of sessions, Termination notes, notation of significant contacts between sessions and other essential documents that are available in our Essential Clinical Forms.
- Including e-mails with clinical records is simple and easy.
- Consent is more than a form to be signed, it is also an ongoing process and dialogue.