Records

Question 1

Therapy records - legal or ethical?

Answer 1

Both! See Business and Prof. Code requirement.

Question 2

How long must I keep adult therapy records.

Answer 2

Must keep records for 7 years after termination.

If a client comes in and leaves and then comes back at a later date, the clock restarts every time the client comes back.

Question 3

How long must I keep therapy records for a minor?

Answer 3

Must keep records for 7 years after termination.

Question 4

What must the record contain to meet the standard of care?

Answer 4

• chief complaint
• document history of complaint
• any testing for which client has been referred out.
• informed consent (if client is a minor, must be signed)
• treatment plan and progress of treatment
• ROI authorization (if applicable)
• start and stop dates of therapy
• any insurance information
• info re: emergency contacts

Question 5

Who owns the records if the therapist works for an agency?

Answer 5

Agency owns the records.

Question 6

Who owns the records when the therapist is in private practice?

Answer 6

The therapist does!

Question 7

How should a client request records?

Answer 7

In writing.

Question 8

If a client requests to come in to review records, how long can I wait to allow client to come in.

Answer 8

Maximum of 5 business days.

Question 9

If a client requests a treatment summary, how long can I wait to provide the summary?

Answer 9

10 business days.

Question 10

If a client requests a copy of the records, how long can I wait to provide the copy? Can I charge a fee?

Answer 10

15 business days to produce. Yes, I can charge $.25 per page.

Question 11

Can the therapist ever refuse access to the records?

Answer 11

Yes. If the therapist determines seeing the full file would be high risk for the client. (If client would be injured by seeing what is in the file)

Question 12

What should I do if I refuse a client access to his/her file?

Answer 12

• document date of client’s request for records
• document specific detrimental consequences foreseen
• notify client of denial
• inform client of right to permit inspection by or to provide copies to another license health professional designated by the client
• if another inspecting professional is authorized, they may not allow the patient to inspect or copy the records.
• the client would need to sign a release and let client know that the other professional cannot provide copy to the client.

Question 13

What if the client wants to add an addendum to their record?

Answer 13

• up to 250 words to correct the record
• addendum would be included if there was an authorization/shared release

THIS IS NOT A COMMON THING

Question 14

When can parents NOT access the records of a minor?

Answer 14

• if it would be harmful to the client

- if it would be harmful to the therapeutic relationship

Question 15

Who can authorize release of the minor’s records?

Answer 15

If a minor is 12 or older, the minor would be the one who would need to sign the release for the records to be shared with anyone, even the parents.

Question 16

when would I need a written ROI?

Answer 16

• release of written records
• for phone conversations with another provider
• when sharing any information about clients

Question 17

What must be contained within the ROI document?

Answer 17

• font can be no smaller than 14 point
• if release is going to be handwritten, the whole release must be in the client’s handwriting
• must list specific uses and limitations of the information (ex. psychiatrist - medication adherence)
• name and function of provider along with my info
• must have an end date
• notification of the patient’s right to copy of authorization
• copy of authorization should be in the client’s record

Question 18

Receiving a release from another provider

Answer 18

• I won’t need a new release unless there is a need

- I would always need a copy