Therapy Records Flashcards
Are holding therapy records both a legal and ethical requirement?
Both a legal and ethical requirement to have records on clients.
If treating an adult how long must you keep their therapy records after the termination of therapy?
Treating an adult you must keep the records for 7 years after termination of therapy.
How long do you keep records for a child client?
7 years after they turn 18 or 25 years old.
How long does a therapist have (amount of business days) to allow a client to physically look at their records in their office when requested by a client?
If a client requests their records a therapist has 5 business days to allow client to physically look at the records in the office.
How long does a therapist have to provide a copy of the treatment summary for a client when requested?
You have 10 business days to provide a treatment summary.
How long does a therapist have to provide a physical copy of their records to a client when requested?
15 business days to produce a copy for a client
If a therapist decides to refuse access or determines that the records will be detrimental to the client what must the therapist do?
The therapist documents the date of request, the specific detrimental consequences, notify client that the request has been received, and that they are denying their request to access to the records. Inform the client that they have a right to permit inspection by another licensed health professional. The person they pick must not allow them access to the records either.
For a minor 12 years or older do you provide the records to the clients parents if requested?
No. Unless you have an ROI from the client.
If a client is under 10 years old do you provide access to their therapy records if parents request them?
If a child is under 10, you would provide access to the records unless the therapist determines that it would be detrimental to the parents or break the therapeutic bond then no.
When should informed consent take place?
Should take place at the onset of therapy and reviewed over the course of treatment as needed.
Do you have to have informed consent signed at the start of treatment?
For adults and children?
According to the law you don’t have to have written (signed) consent unless you’re treating a minor, if you’re treating an adult you do not have to have it physically signed.
Best course of action is to have it signed with all clients.
Should you document if you obtained informed consent?
Yes, especially if it is just verbal consent (Adult consenting).
What should you include in your informed consent?
- Limits of confidentiality.
- Risks and benefits of treatment. “Usually treatment includes feeling worse at some point…”
- Alternative treatments (Medication, physical therapist)
- Cancellation policy
- Fees
- Emergency Situations
- Background of therapist
- Should define who the client is.
- Termination
