Clients Rights and Therapist Responsibilities Ch 5

Question 1

Why do we keep records?

Therapist Responsibility: Record Keeping

Answer 1

maintain high quality service to clients
demonstrates usage of reasonabel standard of care
continuity of care when client is transferred
protects therapist from lawsuit
history of client to review treatment
risk management

Question 2

What are progress notes?

Answer 2

documenting significant clinical decision & are kept in clinical record: (behavioral-what client says and does)

• professional (no personal reactions/opinions)
• describe specific and concrete behavior

-therapists are required by law to keep ( HIPAA )

Question 3

What things are included in progress notes?

Answer 3

• diagnosis
• functional status
• symptoms
• treatment plan
• prognosis
• client progress
• test results
• why treatments were chosen
• goals
• documents (informed consent, release of info)
• dates/frequency/types of services

Question 4

An example of progress notes

Answer 4

Client reports feeling less anxious. She states that her goal would be to haev her anxiety level lowered. Therapist and client agreed to do some guided imagery next session. client reported feeling “unbearably anxious”. Client says the follow activities have helped to lower her anxiety: medication, talking with friends etc.

Question 5

What are process notes? (psychotherapy notes)

Answer 5

private use of therapist:
-personal reactions/opinions of therapist
not mean to be shared - must be kept separate

Question 6

Does the law require process notes?

Answer 6

No

Question 7

Does HIPAA privacy rule allows clinicians to keep 2 sets of records?

Answer 7

YES

Question 8

What is included in process notes?

Answer 8

client reactions (transference) 
therapists subjective impressions
intimate details about client 
info about clients personal life 
therapist thoughts/reactions to client 
hypothesis 

exclude: diagnosis, treatment, symptoms, prognosis & progress

Question 9

Legal requests can be made for documentation of progress notes as well as process notes?

Answer 9

TRUE

Question 10

Example of process notes

Answer 10

client avoided eye contact, client said he was angry for therapist laziness, therapist challenged him to be more active in treatment. after processing, client made connections to feeling inadequate. therapist will follow up next session to see if there are any more feelings surrounding this matter.

Question 11

What is one of the most effective tools counselor shave for successfully responding to licensing board complains or threats of malpractice?

Answer 11

maintaing competent record keeping

Question 12

Any information in the client’s records belongs to the client and can be requested at any time

Answer 12

TRUE

Question 13

What is HIPAA?

Answer 13

health insurance protability and accountability act
established 1996 –> law into effect 2003

increase individuals access and control of medical records

1. privacy standards: how to use and disclose client medical information (whom and when therapists can give patients records)
2. transaction standards: how electronic exchange of info is done
3. security standards: structural protection required to create and maintain info (steps to guard against unintended disclosure of electronic information) ex. strong passwords/firewall

Question 14

what is malpractice?

Answer 14

“bad practice” - legal concept of negligence that results in harm to client

:failure to render prof services or to exercise degree of skill expected

Question 15

ethically and clinically appropriate process of ending a professional relationship

Answer 15

termination

Question 16

failure of therapist to take appropriate steps to terminate a professional relationship

Answer 16

abandonment

Question 17

what may constitute as abandonment?

Answer 17

failure to follow up on outcomes of hospitalized client
not available between appointments
failure to respond to request for emergency treatment
failure to provide for a substitute therapist during vacation
terminating a client who needs continuing care

Question 18

When is it appropriate to terminate a client?

Answer 18

clients are not cooperating with treatment
treatment goals are lost
no progess is being made
goals of therapy reached

Question 19

reasons for malpractice?

Answer 19

failure to obtain informed consent
refusal to counsel client due to differences
client abandonment and premature termination
sexual misconduct with a client
departure from established therapeutic practices
practicing beyond scope of competency
negligent assessment and misdiagnosis
repressed of false memory
unhealthy transference relationships
failure to assess and manage a dangerous client

Question 20

what is the practice of focusing on the identification, evaluation and treatment of problems that may injure clients and lead to filing an ethics complain or malpractice action?

Answer 20

risk management

Question 21

What are risk management strategies?

Answer 21

know and stay up to date on laws & ethics
use treatment contracts “informed consent”
document (termination/referrals)
restrict practice to areas of competency
seek consultation
never accept gifts
don’t egage in relationships with clients

Question 22

what is informed consent?

Answer 22

EDUCATION PROCESS:
the rights of clients to be informed about their therapy and to make autonomous decisions pertaining to it

shared decision making process where therapist provides information so client can decide about participating

Question 23

ethical and legal obligation of the clinician to provide info to clients before they participate in assessment or treatment

Answer 23

informed consent

Question 24

How do you give informed consent?

Answer 24

verbally and written (informed consent document)

Question 25

When do you give informed consent?

Answer 25

as soon as its clinically appropriate must address limits of confidentiality initially may not be appropriate to discuss in great detail during first session; a client's crisis takes precedence over a discussion onf informed consent

Question 26

Why do you give informed consent?

Answer 26

clinical and legal reasons the right of the client to know information increases chance of client being actively involved, educated and willing participants client empowerment / reduce power difference protect therapist from lawsuit/malpractice create boundaries

Question 27

Whom is the information regarding informed consent given?

Answer 27

client and third party payers (insurance)

Question 28

What issues are involved?

Answer 28

health insurance may restrict therapists from sharing full info to clients health insurance request of info

Question 29

Who can give their informed consent?

Answer 29

Competent to make rational treatment Comprehension: understands information Voluntary: acts freely can withdraw at any time

Question 30

What are the exceptions to informed consent?

Answer 30

minors | copy of info to health insurance

Question 31

What is the difference between informed consent and consent to treat?

Answer 31

consent to treat allows client to have treatment explained, challenge/refuse/end treatment, know alternatives and risks/benefits

Question 32

How long does APA say to keep records?

Answer 32

full records kept for 3 years after termination full summary for 12 more years total = 15 years after termination

Question 33

How long does CA law ay to keep records?

Answer 33

adults: 7 years (patients have access) minors: 7 years after 18 years old (25 years old)

Question 34

General standard for record keeping?

Answer 34

minimally keep records or summary for 15 years

Question 35

if a client gives you a written request to inspect their records you must permit inspection within....?

Answer 35

5 working days from receipt of written request

Question 36

if a client gives you a written request to have their records transmitted you must do so within....?

Answer 36

15 days from receipt of written request

Question 37

You can never change a record

Answer 37

TRUE

Question 38

to make changes to a record you must...

Answer 38

put a single line through error, initial it and then write what should be there

Question 39

What 4 components are needed to quality for malpractice?

Answer 39

Duty of Care (prof relationships exists) Standard of Care (negligence by therapist) Demonstrable Harm (harm can be confirmed) Proximate Cause (cause of negligence/harm)

Question 40

What are the top reasons for malpractice cases against therapists?

Answer 40

``` insurance/fee problems sexual activity with adult child custody evaluations non sexual multiple relationships inappropriate response to crisis ```

Question 41

What are the main areas therapists are sued?

Answer 41

``` procedure not professional lack of adequate training for techniques used wrong procedure used failure to warn/protect informed consent issues incompetence ```

Question 42

Therapist setting up a credit card machine is against HIPAA?

Answer 42

TRUE

Question 43

CA law says to keep clients records for 7 years post termination, but this law does not apply to minors

Answer 43

TRUE

Question 44

If a client cannot reach the therapist?

Answer 44

Therapist Responsibilities/Malpractice & Abandonment

Question 45

HIPAA includes: - double locked files - no client names - encrypted internet

Answer 45

TRUE