Recordkeeping in Psychotherapy and Counseling: Ethical, Legal and Clinical Issues (no forms)
Course fulfills the California and other states’ ethics and law requirements.
Course may qualify for insurance discount. Check with your insurer.
Proper recordkeeping is an area of practice that is confusing and unclear to many practicing psychotherapists and counselors. What to put in the records? How long to keep records? Is it better to keep records online or on the cloud? What to do if I’m subpoenaed? When can I dispose of records, and what’s the best way? These are some of the pressing questions around recordkeeping that therapists face. The time to get answers is now, before legal or clinical issues become acute and the records are under scrutiny. This course teaches best practices for recordkeeping, the relevant laws and regulations, how to respond if issued a subpoena, and the best ways to deal with third-party payers who request records, among many other relevant issues.
This intermediate level course begins with an introductory section on recordkeeping guidelines. This section includes a text overview and audio interview with ethicist and scholar, Dr. Michael Donner. The second section contains an article on informed consent and the process of obtaining and retaining informed consent throughout treatment. The third section contains an article on how to respond to subpoenas. Additional references are provided for further study, but they are not part of the course.
Educational Objectives
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Learn the current laws and regulations regarding recordkeeping
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Discuss the issues involved in keeping records electronically or online
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Evaluate current recordkeeping practices
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Prepare to respond to subpoenas in an appropriate manner
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Utilize clinical forms in psychotherapy practice
Syllabus
- Overview of documentation and record-keeping
- Reasons to document
- Clinical
- Ethical
- Legal
- What belongs in clinical records
- Client information
- Clinical developments
- Termination information
- Testing, crisis, and other relevant information
- Relevant ethical issues
- Clinical matters
- Principles
- Codes
- Standards
- Legal issues (including CA law)
- HIPAA
- How long to keep records
- Subpoenas
- How to respond
- Protecting clients’ confidentiality
- Giving the minimum information needed
- Patriot Act and special circumstances
- Codes of Ethics
- Guidelines from professional associations
