Therapy records / Professional Will Flashcards
Maintaining therapy records is ?? matter.
legal and ethical
I need to keep therapy records for ? years for adults.
7
I need to keep therapy records until ? for children.
age 25 (7 years after turning 18)
Therapy records must be stored in?
locked, inaccessible to others location
What information need to be in therapy records?
- chief complaint
- any findings from consulting other professionals
- signed consent
- treatment plans and progress notes
- ROI
- Insurance information
- Emergency contact
8 Any crisis related records
Therapy records are owned by?
therapist or her/his agency
In order to request records, patient must?
make a written request
Therapist has ? days to allow patient to inspect/read records.
5 business days
Therapist has ? days to give patient a treatment summary.
10 business days
Therapist must provide a copy of records in ? days.
15 business days
When can a therapist refuse to release patient records to the patient?
There is a high possibility for detrimental consequences.
When refusing to release patient records to the patient, therapist must do ??
- note the date of the request.
- document a specific detrimental consequences foreseen.
- Inform the client that I received the request and that denying the request.
- Inform the client his/her right to have another licensed professional to inspect/receive records.
When a patient found an error in his/her record, he/she has a right to request ?
addendum to correct the record for up to 250 words.
When can I refuse to release minor’s records to parents?
If I believe releasing records would harm the minor or our therapeutic relationship (only for kids under 12).
If a client is old enough to consent (12 or older), what needs to be done when parents/others request records?
The minor patient (12 or older) must sign consent.
I must have a ? to share patient information with others.
a written release (not verbal)
The font on release form must be ?
14 or larger
If you don’t have a printed ROI on hand, what should I do?
Patient must handwrite the form her/himself on a piece of paper.
ROI must specify ? (2)
- what information to be disclosed
2. the name and function of person receiving info.
ROI must have ? date and patient’s right to?
end date
a copy of the authorization/ROI
When I receive ROI from other professionals, I don’t need ?
my own ROI signed by patient.
What is Professional Will?
A document that outlines what need to be done if I die or become incapacitated unexpectedly.
Professional Will designates ?
a licensed professional that will oversees patient referrals.
Professional Will tells ?
where records are kept and who will maintain them.
