10.36.05.08 Confidentiality and Client Records Flashcards
What are the 8 standards concerning confidentiality and client records?
A psychologist shall:
1) MAIN CONF: maintain confidentiality regarding information obtained from a client in the course of the psychologist s work.
2) @ BEGINNING: discuss the requirements and limitations of confidentiality at the beginning of the professional relationship or at the intake.
3) PROTECT MINIONS: safeguard information obtained in clinical or consulting relationships or evaluative data concerning children, students, employees, and others obtained in the course of practice, teaching, research, or other professional services.
4) APPROP RELEASE: release mental health records or other confidential info only as permitted or required by law.
5) PERM to RECORD: obtain written permission for the electronic recording of interviews.
6) ONLY RELEVANT: avoid undue invasion of privacy by ensuring that written and oral reports contain only data relevant to the purpose of the evaluation.
7) ANY RESULT: treat any assessment result or interpretation re: an individual as confidential info.
8) PRESENT: obtain written consent before presenting in writing, lecture, or other public forums, identifying info obtained during the course of professional work, and disguise this info when case reports or other confidential info are used as a basis for teaching or research.
What are the 4 standards re: informing individuals of (explaining) the legal and ethical limits of confidentiality?
A psychologist shall inform:
1) clients of the legal and ethical limits of confidentiality.
2) clients below the age of minority, or who have legal guardians, of the limits the law imposes on the right of confidentiality with respect to communications with the psychologist, to the extent that the client can understand, at the beginning of the professional relationship.
3) research participants of any limits to confidentiality as part of the informed consent.
4) clients of the duty imposed by law to inform authorities of abuse and neglect of children and vulnerable adults.
What information must be included in the documentation of a client’s record? Hint: 7 things.
1) record of informed consent
2) presenting problems
3) diagnosis
4) fee arrangements
5) dates and substance of each billed service
6) original test data with results and other evaluative material
7) results of any formal consultations with other professionals
What are the 6 standards re: record keeping?
A psychologist shall:
1) KEEP: keep records of a client’s condition and assessment results (keep written or electronic records of all professional contacts).
2) MAINTAIN: maintain clinical records with all the needed info.
3) STORAGE & DISPOSAL: make provisions for maintaining confidentiality in the storage and disposal of written and electronic records.
4) TIME: ensure that professional records are maintained for a period consistent with State and federal laws.
5) MINIONS PROTECT: limit access to client records and ensure that all individuals working under the psychologist’s authority (e.g., psychology associates, office personnel) comply with the requirements for confidentiality of client material.
6) RELEASE APPROP & ON TIME: provide evaluations or treatment reports within a reasonable time consistent with State and federal laws upon proper and lawful requests by a client, insurance carrier, court, institution, or other authorized health provider. Be sure that there is appropriate consent for the release of records in each of these situations.
