Explore Record Keeping Requirements Psychology 5103 Week 2

Explore Record Keeping Requirements Psychology 5103 Week 2: Record Keeping Requirements Suzanne Zuiderweg-Mc. Elomoyl zuiderweg

Why should you keep records ? Ø It helps with continuity. Ø It is unethical not to keep records. Ø Expert opinions in case of civil, criminal or administrative litigation. Ø If you become disabled or cannot continue care, records help the next therapist. (Zur, 2015) zuiderweg Figure 1. Record keeping (google. com/images)

Keeping Records & Record Retention Ø Follow state, federal, professional organizations and HIPAA guidelines for record keeping. (Leslie, 2011) Ø “Create, maintain, disseminate, store, retain and dispose of records and data relating to professional or scientific work. ” APA standard 6. 01 Figure 3. Binge Drinking (google. com / image) zuiderweg

Keeping Records & Record Retention (Basics) q Store hard copy records in a safe, locked, reasonably protected from theft, intrusion, fire, earthquake, water damage and unauthorized access. q. Protect computer records by use of password, virus protection, firewall and access log. Backup regularly and store backup off site in secure location. Use access log if necessary for any printed hard copies. q Enter clinically relevant and meaningful information in the clinical record. q Take caution with phone messages and anyone that may have access to information must use a confidentiality policy zuiderweg

Record Keeping for Psychotherapy Figure 4. Psychotherapy (google. com / image) q Include mental status exam and diagnosis/presenting problem, fee agreement and treatment plan. q Prior to treatment present client with Office Policies and Informed Consent forms. Include in record. q Update record for treatment plans and progress or lack thereof, as necessary. q Record should reflect your competence, thoughtfulness, decision-making ability, available options, rational for treatment selection, and your knowledge of clinically, ethically and legally relevant matters. q Document special occurrences, phone calls, emergencies, dangerousness, consultations, testing, referrals, contacts. q Summary of termination: who initiated, reasons, achievements. q Do not include superfluous details, that could cause harm to client. q Maintain records for required time. (California 7 years) q Destroy records by shredding or burning. (Zur, 2015) zuiderweg

Record Keeping Controversies and what you can do. Ø There is power in a clinical record. Facts in this record can affect one’s life: Child custody, security clearance, accommodations for a disability. ( Pope, 2015) Ø If record security is breached: Sensitive and private information may lead to : “ ridicule, identity theft, exposure on social media” (Pope, 2015 p. 348) Ø Technology requires professionals to act proactively to confidentiality threats. Ø Proactive action: “Maintain mindfulness about clinical records, take an active thoughtful, and creative approach to your responsibility, stay aware of relevant legislation on record keeping” (Pope, 2015 p. 353) Ø Only relevant information for treatment should be included in the record (Bermister & Dobson, 2011). zuiderweg

APA Standards: Privacy & Confidentiality ØObligation to take reasonable precautions to protect confidential information. You are responsible for knowing methods to take. ØPrecautions differ according to your role. ØYou must attain informed consent. ØKnow guidelines for disclosure of confidential information. (Ethics & Laws) Figure 2. confidentiality (google. com / image) zuiderweg

Disclosing Confidential Information APA Ethics Code Ø Consider the four bins: Legal, clinical, ethical and risk management. Ø Disclose with consent Ø Disclose when mandated by law or valid purpose. Ø Ø A. provide needed services B. obtain professional consultations C. protect client, psychologist or others from harm D. obtain payment for services, in minimal amount to achieve purpose of payment (APA Ethics Code 4. 05) (Fisher, 2017) zuiderweg

HIPAA Health Insurance Portability and Accountability Act 1996. Basic Privacy Rules set by Federal Government Ø Provide notice of privacy practices Ø Rights on PHI (Protected Health Information) Ø Informed Consent Ø Right to : restrict disclosures, notify of any breach of unsecured PHI, opt out of fundraising (communications), authorization of anything not listed in notice. Ø Designated HIPAA officer, if applicable Ø HIPAA has requirements for staff members who have access to PHI. Ø All of those who are on the research or health care team must follow procedures for HIPAA. (Leslie, 2011) For additional information on HIPAA: https: //www. gpo. gov/fdsys/pkg/PLAW 104 publ 191/html/PLAW-104 publ 191. htm zuiderweg Figure 5 Hipaa ( google image)

California Law: Board of Psychology: Record Keeping Ø California Health and Safety Code ~123105, states that the following must be in the clinical record. 1. Intake and evaluation note 2. Progress notes 3. Dates of Sessions 4. Fees and payments 5. Clinical info: diagnosis, treatment plan, psych testing. 6. Records from other providers 7. Psychotherapy notes 8. Discharge notes Records must be kept for 7 years after patient’s discharge date, records for minors must be kept for 7 years after they turn 18. https: //ce 4 less. com/Tests/Materials/E 070 Materials. pdf zuiderweg

California Law: Confidentiality of Medical Record California follows the confidentiality Code of Conduct set by APA. Right to confidentiality is not absolute. Exceptions of patient privilege. CA Evidence Code 1014 Ø Reasonable suspicion of child abuse or elder adult physical abuse. Ø Reasonable suspicion that a person may present a danger of violence to others. Ø Reasonable suspicion that a person is likely to harm him or herself unless protective measures are taken. Reasonable suspicion occurs when “it is objectively reasonable for a person to entertain such a suspicion, based upon facts that could cause a reasonable person in a like position, drawing when appropriate on his or her training and experience. ” (California Law and Ethics) https: //ce 4 less. com/Tests/Materials/E 070 Materials. pdf zuiderweg

References Bemister, T. B. , & Dobson, K. S. (2011). An Updated Account of the Ethical and Legal Considerations of Record Keeping. Canadian Psychology, 52 (4), 296 -309. https: //doi. org/10. 1037/a 0024052 California Law & Ethics for Psychologists: Key Concepts Review. (2015). Retrieved from https: //ce 4 less. com/Tests/Materials/E 070 Materials. pdf Ethical Principles of Psychologists and Code of Conduct. (2017). Retrieved from http: //apa. org Fisher, C. B. (2017). Decoding the Ethics Code: A practical guide for psychologists (4 th ed. ). HIPPA Regulations: Federal Government : https: //www. gpo. gov/fdsys/pkg/PLAW-104 publ 191/html/PLAW-104 publ 191. htm Leslie, R. S. (2011). Psychotherapy Notes and Psychotherapy Records. Retrieved from https: //www. cphins. com/psychotherapy-notes-and-psychogherapy-records/ zuiderweg

References Pope, K. S. (2015). Record-Keeping Controversies: Ethical, Legal, and Clinical Challenges. Canadian Psychology, 56, (3), 348 -356. https: //doi. org/10. 1037/cap 0000021 Zur, O. (2015). Record Keeping Guidelines for Psychologists, Counselors, MFT’s, Social Workers In private Psychotherapy and Counseling Practice. Retrieved from https: //www. zurintitute. com/recordkeepingguidelines. html zuiderweg