Lecture 2 Flashcards
Record Keeping and Fees
6.01 Documentation - have to document treatment, research, etc. Balance between confidentiality and documenting enough to know what happened. 6.02 - Maintenance - paper, electronic, financial/billing. 6.03 Withholding for nonpayment - can’t do that, also best to not let clients run up a bill. 6.04 - fees and financial arrangements - have to let them know fees and payment expectations up front.
Record keeping guidelines APA 2007
Aspirational, use professional judgment. Why keep records: risk management, track progress, other medical practitioners might need them, facilitating later treatment. Retention of records: know state law. HIPAA - 6 years except for psychotherapy notes (no timeline, don’t have to create them, can destroy them whenever), you also have to develop a practice policy that defines what a treatment record consists of (basic info is required like date, fee, problem, basic service). Medicare is 7 years (longest of any federal requirement). Minor - 3 years after age of majority (if that’s later than the other requirements). Nothing says you have to destroy the records though. In absence of state law, 7 years after last contact of 3 years after minor attains majority (whatever is later). Look at requirements of agency you work with (VA has 10 year requirement).
Records in marital and family therapy
10.02 When serving multiple people who have a relationship, make clear at outset which of the individuals are clients/patients and the relationship the psychologist will have with each of the people. Keep records according to this. No established way, just the way that you choose to do it: record for whole family, each person, one person only, etc. Establish clear rules at the beginning, inform everyone, and document. Several positions clinician can take: no secrets/no confidentiality, treat each member as an individual in therapy (all confidential), accept confidences only with understanding that you will help them reveal to other family members.
Records in group therapy
10.03 - when provide to several persons in group, describe at outset roles and responsibilities of all parties and limits of confidentiality. Keeping separate record for each person in the group is a good idea. If it’s more of a subject group rather than a process group - can just put same info for treatment content in each record, still better to have separate records so that other people’s info doesn’t get released. No privilege exists between group members. Once someone has shared something in a group, it’s not privileged because it’s shared with others in the group as well. Discourage relationships with others in the group because taking sides can happen.
Interruption of services
10.01 - inform of course of therapy and what to expect at the beginning. 10.10 a - terminate when no longer benefiting, point of accomplishing goals, or are being harmed. 10.10 b - can terminate if you feel threatened. 10.10 c - termination counseling, suggest alternatives. Either client or therapist can initiate stopping. 3.12 - interruption of services - unless otherwise covered by contract, make reasonable efforts to plan for facilitating them in case they are interrupted by illness, death, etc. 10.09 - interruption of therapy - make reasonable efforts to provide for appropriate resolution of responsibility for client care in event that the relationship ends (paramount consideration for welfare of client)
Scenario
1.03 - making conflicts known.
Death of psychologist
Have instructions in your will or your psychology practice procedures. If no instructions, follow APA specialty guidelines. Who lets patients know, who has keys, etc. If nothing, licensing board can appoint psychologist to help them address the issue.
