Treatment Records/Privilege

Question 1

Adequate Documents = Standard of Care (Ethical)

Answer 1

Core Elements Expected - Informed Consent, Assessment Prog with DX, Tx plans and goals, Each individual. service, collateral contact, consultation, termination and financial records

Question 2

Consent

Answer 2

Verbal or written, but documented

Question 3

Assessment Prog with DX

Answer 3

If you’ve dx, how you got there (assessments, etc)

Question 4

Tx plans and goals

Answer 4

Plan on how you intend to work with clt a

Question 5

Each individual service

Answer 5

Progress note with date, time, assessment, srvc performed, assess for risk, intervention, plan moving forward

Question 6

Collateral Contacts

Answer 6

Outside providers communicating with

Question 7

Consultation

Answer 7

always document case consultation

Question 8

Termination

Answer 8

Whether mutual or after clt has stopped coming w/o communication. Always close files.

Question 9

Financial records

Answer 9

record all payments

Question 10

Documentation Laws

Answer 10

No standard about content of file so we keep up with standard of care (informed consent, assessment and dx, tx goals and plan, each individual service, collaboration contact, consultation, termination and financial records)

Question 11

Documentation Laws - storage

Answer 11

“securely kept” - lock and key OR encryption; 7yrs; 7yrs after 18 - including if you see a family and there are kids under 18, will keep until 7 years after youngest turns 18

Question 12

Clt Access to Documentation

Answer 12

Entitled to review or receive records - 5 days respnse time to review, 15 to receive a copy. Clinician can determine whether it would be harmful or not for clt. Clt can challenge clinician’s reply by asking a 3rd party MFT to review and determine whether or not they would be harmful or detrimental to have.

Question 13

Minors and Documentation

Answer 13

Those that have consented on their own, have authority to review or release records.

Question 14

Subpoena

Answer 14

DX who its from - privately or a judge; always have to respond regardless who it’s from

Question 15

Private source

Answer 15

contact clt to determine if they want to release or you to testify; sign authority (this is a response)

Question 16

Assert Privilege

Answer 16

Clt wants neither release or testify; (also a response) assert privilege on their behalf to the subpoena source

Question 17

Never Assume Privilege

Answer 17

If unable to reach clt never assert privilege on their behalf until they share what they want

Question 18

Court Order

Answer 18

Judge has already determined course of action; have to comply

Question 19

Privilege Comm. Examples

Answer 19

spouse
lawyer/clt No testifying against
therapist/clt
care provider (dr)/patient

Question 20

Who holds clt privilege

Answer 20

Clt does - even minors and dependent adults. May not be able to wave on their own behalf, requiring a judge to determine their best interest.

Question 21

Privilege Coming Out

Answer 21

therapy confidentiality is broken and information is allowed into a legal proceeding — like a court trial or hearing.

Question 22

Privilege Coming Out - Examples

Answer 22

Subpoena - records, testify or both
clt determines their wishes

Question 23

Exceptions to Privilege in CA Law

Answer 23

1. clt makes mental or emotional claim
2. clt alleges breach of duty by therapist
3. Tx or eval is court ordered
4. eval or therapy to verify sanity
5. under 16, victim of a crime and disclosing is in clts best interest (lawyer asserts for and judge makes determination)
6. sought out by clt for purpose of committing a crime or avoiding detection after the fact