ch 6 Flashcards
records and subpoenas
records
any physical recording made of information related to a counselors professional practice
clinical case notes
notes that counselors take concerning sessions with clients
types of records
appointment books
billing and payment accounts
copies of correspondence
intake forms
other routine papers
audio recordings or video recordings
unusual records
records of clients logging on to computerized information systems
telephone bills indicating clients numbers called
computerized records that clients had used for parking or building passes
video recordings of clients entering or leaving a counseling office
purpose of records
rendering professional services to their clients (primary purpose ethically)
benefit the client because they allow the counselor to summarize each interaction with the client and record plans for future sessions
keep track of which treatments chosen and why
can help measure change and goals of clients
used for continuity of care
used as evidence to prove care during crisis `
continuity of care
a consideration when a client is referred from one mental health professional to another as well
if counselors ask themselves why they are writing a note for a client record, who will read the record, and what those who read it will be looking for….
there will be a better chance that the record will be appropriate for its purpose
A.1.b of code of ethics states that
counselors include in their records sufficient and timely documentation to facilitate the delivery and continuity of services
standard B.6.b
addresses the importance of keeping records in a secure location
standards B.6.c and B.6.d
address the issue of informed consent and require counselors to obtain client permission before they electronically record or observe sessions
standard B.6.e
alerts us to the fact that we have an ethical obligation to provide competent clients with access to their records, unless the records contain information that might be misleading or detrimental to the clients
standard B.6.g
requires counselors to obtain written permission from clients to disclose or transfer records to legitimate third parties unless exceptions to confidentiality exist
when transferring records, include…
a cover letter that explains the confidential nature of any transferred records, mark each page confidential, and include a statement on the records that the copy of the records is not to be transferred to any third party
standard B.6.h
provides guidelines to counselors regarding storage and disposal of counseling records after a counseling relationship has ended
standard B.6.i
imposes on counselors the duty to take reasonable precautions to protect their clients privacy if counselors terminate their practice, become incapacitated, or die
before counselors sign a contract with a third part/health insurance organization they should…
learn the type, frequency, and extent of patient information to the organization requires in order to authorize and review treatment
should be discussed with clients
standard B.3.d
requires counselors to obtain authorization from their clients before disclosing information to third-part payers
legal principles indicate
that the contents of the records about a particular client belong to that client, even though the paper or recording instrument belongs to someone else
counselors maintain documentation…
necessary for rendering professional services
no set standard technically
standard A.1.c
requires that counselors develop counseling plans with their clients and revise the plans as necessary
does not specify it should be in writing
standard A.2.a
states that counselors have an obligation to review in writing and verbally with clients the rights and responsibilities of both counselors and clients
standard B.6.g
requires a written record of permission to transfer records
administrative records
any types of records that would not be considered recordings or clinical case notes
include appointment books, billing and payment accounts, copies of correspondence, signed informed consent documents, client permission to release information, intake forms, and other routine papers that are created as a result of providing counseling services to clients ‘
**in most businesses, records of these type are not considered confidential (identities must be protected though)
recordings
counselor can record to show client their behavior/empathize
must inform them that until it is deleted, the recording will be available for subpoena
have them sign a form to ensure hey understand the problems that might arise and their responsibility for their own privacy protection
procedures to follow when recording client sessions
clients must know recording is being made and must agree to the process
must be informed as to why the recordings are being made and who accessed them
which record concerns counselors and clients the most?
clinical case notes
when writing clinical case notes, assume…
notes will be read by others
your clients have a legal right to review the notes and to obtain copies of them
your clients have a legal right to demand that you transfer copies of those clinical case notes to other professionals, including other mental health professionals attorneys, physicians, and even accountants
your clients can subpoena the clinical case notes when they are involved in litigation
other parties can legally subpoena the clinical case notes when involved in litigation situations involving the client, sometimes over the clients objections and even when the records are privileged, if legal exceptions to privilege exist
the legal representatives of decreased clients, in most states, have the same rights to clinical case notes as the clients had when they were alive
clinical case notes sometimes do become public information and get published in the media
the purposes of clinical case notes
- to provide quality counseling services to clients
- to document decisions you have made and actions you have taken as a counselor
advice for clinical notes
critical you take notes during or immediately after session
separate objective information (what was said or observed) from your clinical impressions (hypotheses or conclusions you develop as a result of what was said or observed)
SOAP notes
common format for clinical case notes
Subjective: info reported by the client
Objective: results of the counselors tests and other assessments administered
Assessment: the counselors impressions generated by the data
Plan: diagnosis and treatment plan, along with any modifications to them
DAP notes
Data: objective description of what occurred during the session
Assessment: counselors interpretations based on the data, in the context of the presenting problem and treatment plan
Plan: what the counselor intends to accomplish in the next session or sessions
when a client requests case notes
if information may harm them try to convince otherwise, but they still have the right to it
documentation through records for self-protection
1.Document in circumstances in which your actions or inaction may be later reviewed by an ethics panel, licensure board, or administrator, or within the context of a legal proceeding.
2. Some of the situations in which some level of documentation is called for include the following:
* Someone accuses a counselor of unethical or illegal behavior.
* A counselor reports a case of suspected child abuse.
* A counselor determines that a client is a danger to self.
* A counselor determines that a client is a danger to others.
* Aclientwhoisbeingcounseledisinvolvedinalegalcontroversythatcouldleadtothecounselorbeingforced to testify in court. Such controversies include counseling a child whose parents are arguing about custody in a divorce case, a husband or wife involved in a contentious divorce case, a couple contemplating a divorce, or a person involved in a personal injury lawsuit.
3. Begin documenting as soon as you determine that the situation is one in which documentation is important.
4. When documenting for self-protection, include as much detail as possible. Include dates, exact times events occurred, and exact words spoken to the degree that those details are remembered. Include only factual infor- mation. When documenting, avoid your thoughts, diagnoses, and conclusions. If these must be written down,
include them in clinical case notes rather than in records kept for documentation.
5. The best documentation is created very soon after a conversation or event has occurred. Indicate the date and
time anything is written, and never backdate anything. In other words, do not imply or state that something
was written on an earlier date than it was actually written.
6. If you realize that you should have begun documentation sooner, write a summary of what happened up to
that point in time. Include as much detail as can be remembered, as well as the date and time the summary
was written.
7. Maintain a documentation file that includes the originals of notes written to counselors, copies of notes writ-
ten by counselors to others, copies of relevant papers that counselors cannot keep for themselves, and other
papers that might be relevant to the situation.
8. Keep documentation records safe in a locked file drawer or cabinet or in a secure computer file. If counselors
agree to provide their files, they should never release their originals, only copies.
the most far-reaching federal law related to mental health records is
HIPPA
HIPPA statute required
HSS to issue privacy regulations governing individually identifiable health information if congress did not enact privacy legislation within 3 years of the passage of HIPPA
applies only to organizations and individuals who transmit health care information in connection with a health care transaction
HIPPA privacy rule
all records and other individually identitfiable health information held or disclosed by a covered entity in any form – whether communicated electronically, on paper, or orally
disclosures of treatment information without specific consumer authorization are allowed in certain circumstances…
quality assurance, oversight activities, research, judicial and administrative hearings, limited law enforcement activities, emergency circumstances, and facility patient directories
clinical case notes are know as…
psychotherapy notes under HIPPA
the family educational rights and privacy act of 1974 (FERPA) (Buckley amendment)
affects all public educational institutions and any private or parochial educational institution that receives federal funding in one form or another
two rights of FERPA legislation for minor students parents and 18 or older
- to inspect and review their education records and to challenge the contents to ensure the records are not inaccurate or misleading,
- to have their written authorization obtained before copies of their education records can be transferred to any third party
dependent students
defined as children or stepchildren, over half of those support was received from the taxpayer the previous tax year
education records
defined in the federal legislation as records kept by educational institutions regarding students
“the sole possession of the maker”
FERPA does not require schools
to obtain written permission from parents or students to release a students records to other schools or school systems in which the student intends to enroll
emergency situations was well
the comprehensive alcohol abuse and alcoholism prevention, treatment, and rehabilitation act of 1972 declares
that records kept by any facility that is conducted, regulated, or directly or indirectly assisted by the federal government are confidential
violation can lead to criminal charges and a fine
the circumstances where disclosure of records of individuals receiving substance abuse services include
- when the person gives prior written consent
- in medical emergencies
- for audits or evaluations
- to avert substantial risk of death or serious bodily harm if a court ordered is secured
**can not be used for criminal charges or investigations (counselors direct observations can)
other federally assisted programs that have federal statutes
- runaway and homeless youth
- individuals with sexually transmitted diseases
- voluntary clients in federal drug abuse or dependency programs
- older persons
- victims of violence against women
exceptions to destroying records
- there is a reason to believe the records may be subpoenaed in a current or future lawsuit
- the records contain documentation of actions taken by counselors that will be kept longer than the usual period of time
**establish record-destroying policies
subpoenas
legal documents that might require counselors to produce copies of records; appear for a deposition, court hearing, or trial; or appear and bring their records with them
official and can’t be ignored
consult with attorney prior
discovery
the process whereby attorneys have the right to ask or and receive information relevant to their case before the case is tried `
when getting a subpoena…
- if employed, notify your immediate supervisor that you have received a subpoena and to request legal advice regarding your response to it
interrogatories
easiest type of subpoena
set of written questions with a requirement that you respond to each question in writing
