Therapy records / Professional Will

Question 1

Maintaining therapy records is ?? matter.

Answer 1

legal and ethical

Question 2

I need to keep therapy records for ? years for adults.

Answer 2

7

Question 3

I need to keep therapy records until ? for children.

Answer 3

age 25 (7 years after turning 18)

Question 4

Therapy records must be stored in?

Answer 4

locked, inaccessible to others location

Question 5

What information need to be in therapy records?

Answer 5

1. chief complaint
2. any findings from consulting other professionals
3. signed consent
4. treatment plans and progress notes
5. ROI
6. Insurance information
7. Emergency contact
   8 Any crisis related records

Question 6

Therapy records are owned by?

Answer 6

therapist or her/his agency

Question 7

In order to request records, patient must?

Answer 7

make a written request

Question 8

Therapist has ? days to allow patient to inspect/read records.

Answer 8

5 business days

Question 9

Therapist has ? days to give patient a treatment summary.

Answer 9

10 business days

Question 10

Therapist must provide a copy of records in ? days.

Answer 10

15 business days

Question 11

When can a therapist refuse to release patient records to the patient?

Answer 11

There is a high possibility for detrimental consequences.

Question 12

When refusing to release patient records to the patient, therapist must do ??

Answer 12

1. note the date of the request.
2. document a specific detrimental consequences foreseen.
3. Inform the client that I received the request and that denying the request.
4. Inform the client his/her right to have another licensed professional to inspect/receive records.

Question 13

When a patient found an error in his/her record, he/she has a right to request ?

Answer 13

addendum to correct the record for up to 250 words.

Question 14

When can I refuse to release minor’s records to parents?

Answer 14

If I believe releasing records would harm the minor or our therapeutic relationship (only for kids under 12).

Question 15

If a client is old enough to consent (12 or older), what needs to be done when parents/others request records?

Answer 15

The minor patient (12 or older) must sign consent.

Question 16

I must have a ? to share patient information with others.

Answer 16

a written release (not verbal)

Question 17

The font on release form must be ?

Answer 17

14 or larger

Question 18

If you don’t have a printed ROI on hand, what should I do?

Answer 18

Patient must handwrite the form her/himself on a piece of paper.

Question 19

ROI must specify ? (2)

Answer 19

1. what information to be disclosed

2. the name and function of person receiving info.

Question 20

ROI must have ? date and patient’s right to?

Answer 20

end date

a copy of the authorization/ROI

Question 21

When I receive ROI from other professionals, I don’t need ?

Answer 21

my own ROI signed by patient.

Question 22

What is Professional Will?

Answer 22

A document that outlines what need to be done if I die or become incapacitated unexpectedly.

Question 23

Professional Will designates ?

Answer 23

a licensed professional that will oversees patient referrals.

Question 24

Professional Will tells ?

Answer 24

where records are kept and who will maintain them.