Clients Rights and Therapist Responsibilities Ch 5 Flashcards
Why do we keep records?
Therapist Responsibility: Record Keeping
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
What are progress notes?
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 )
What things are included in progress notes?
- 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
An example of progress notes
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.
What are process notes? (psychotherapy notes)
private use of therapist:
-personal reactions/opinions of therapist
not mean to be shared - must be kept separate
Does the law require process notes?
No
Does HIPAA privacy rule allows clinicians to keep 2 sets of records?
YES
What is included in process notes?
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
Legal requests can be made for documentation of progress notes as well as process notes?
TRUE
Example of process notes
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.
What is one of the most effective tools counselor shave for successfully responding to licensing board complains or threats of malpractice?
maintaing competent record keeping
Any information in the client’s records belongs to the client and can be requested at any time
TRUE
What is HIPAA?
health insurance protability and accountability act
established 1996 –> law into effect 2003
increase individuals access and control of medical records
- privacy standards: how to use and disclose client medical information (whom and when therapists can give patients records)
- transaction standards: how electronic exchange of info is done
- security standards: structural protection required to create and maintain info (steps to guard against unintended disclosure of electronic information) ex. strong passwords/firewall
what is malpractice?
“bad practice” - legal concept of negligence that results in harm to client
:failure to render prof services or to exercise degree of skill expected
ethically and clinically appropriate process of ending a professional relationship
termination
failure of therapist to take appropriate steps to terminate a professional relationship
abandonment
what may constitute as abandonment?
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
When is it appropriate to terminate a client?
clients are not cooperating with treatment
treatment goals are lost
no progess is being made
goals of therapy reached
