Record Keeping

Front 1

purpose of record keeping

Back 1

provide the best service possibel for clients and provide a asis for safeguarding practiiones en the event of a lawsuit by documenting thier decisons and the actions they have taken.

Front 2

Objective of record keeping

Back 2

to structure quality care, to decrease liability exposure and to fulfill requirements for reimbursements. and to provide quality services to clients.

Front 3

Clinicians reasons for not keeping records

Back 3

violating client's confidentiality and privacy, tx do not have time to keep notes on their clients.

Front 4

What should be included in a clients record:








Items to include in a client's record

Back 4

name of client;s primary physician, objective finding from the most recent physical examiniont, intake sheet; documentation of a mental status exam or assessment ; signed informed consent for treatment form, diagnosis and prognosis; treatment plan, goals, etc.

Front 5

Accesing minors records

Back 5

Parents should have access to all school records of students under the age of 18 and to students themselves once they reach 18.

Front 6

Keeping records

Back 6

a therapist is required ethically and legally to keep records in a secure manner and to protect client confidentiality.

Front 7

How long to keep a record?

Back 7

Providers have an obligation to keep records for a minimum of 7 years following the termination of a client. In the absence of a record keeping policy records should be kept for a minimum of 3 years after the last contact with a client. records of a summary , should then be maintained for an addiotional 12 years before disposal.

Front 8

Safe keeping records

Back 8

Counselors ensure that records are kept in a secure location and that only authorized persons have access to records.

Front 9

Permission to records

Back 9

Counselors obtain permission from clients prior to recording sessions through electronic or other means.

Front 10

Client's access

Back 10

Counselors provide reasonable access to records and copies of records when requested by competent clients. Counselors limit the access of clients to their records, or portions of their records, only when there is compelling evidence that such access would cause harm to the client. Counselors document the request of clients and the rationale for withholding some or all of the record in the files of clients. In situations involving multiple clients, counselors provide individual clients with only those parts of records that related directly to them and do not include confidential information related to any other client.

Front 11

transfer of records

Back 11

Counselors must obtain client consent to disclose or transfer records to third parties

Front 12

Informed consent

Back 12

Marriage and family therapists obtain appropriate informed consent to therapy or related procedures as early as feasible in the therapeutic relationship, and use language that is reasonably understandable to clients.

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Informed consent content

Back 13

informed consent generally necessitates that the client: (a) has the capacity to consent; (b) has been adequately informed of significant information concerning treatment processes and procedures; (c) has been adequately informed of potential risks and benefits of treatments for which generally recognized standards do not yet exist; (d) has freely and without undue influence expressed consent; and (e) has provided consent that is appropriately documented.

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inabiity to sign informed consent

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When persons, due to age or mental status, are legally incapable of giving informed consent, marriage and family therapists obtain informed permission from a legally authorized person, if such substitute consent is legally permissible.

Front 15

Current clients relations

Back 15

Sexual or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited.

Front 16

Former clients relationships

Back 16

Sexual or romantic counselor–client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. Counselors, before engaging in sexual or romantic interactions or relationships with clients, their romantic partners, or client family members after 5 years following the last professional contact, demonstrate forethought and document (in written form) whether the interactions or relationship can be viewed as exploitive in some way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering such an interaction or relationship.

Front 17

Non professional interartions or relattionships

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client nonprofessional relationships with clients, former clients, their romantic partners, or their family members should be avoided, except when the interaction is potentially beneficial to the client.

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Counselor stopped practicing or retire

Back 18

Therapists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists' withdrawal from positions or practice.

Front 19

Confidentiality

Back 19

Confidentiality will be maintained for all clients with the following exceptions:

If the client poses a "clear and imminent danger to his/her self or someone else including family members.

If you are abusing a child or if you have plans for violence, confidentiality does not apply

Front 20

Confidentiality

Back 20

confidentiality rule does not apply if clients disclosed of any information regarding risk of harm to themselves and/or others.

Front 21

Confidentiality

Back 21

means that all clients’ information obtained during interviews, counselling, educational programmes, and/or at any other form of communication, verbal or written must be kept confidential at all times

Front 22

Priviliged communication

Back 22

Privielege is the clients right to prevent a mental health professional from revealing confidentail communication is a legal preceeding. Provileged conmmunication that is established by statute can protect clients from disclosure in a legal proceeding.

Front 23

suggestions for counselors to divulge requested information

Back 23

Make use of informed consent statements regarding the parameters of confidentiality. Inform cients of the situation and involve them in the process. Take reasonable steps to protect client confidentiality. If information is required to be disclosed, provide only minimal disclosure. With permisiion, contact the client's attorney.
Document all actions taken and what information was disclosed. Make it a practice to consult with colleagu regarding clinical judgments and with attorneys regarding legal obligations.

Front 24

Privacy

Back 24

Counselors respect client rights to privacy. Counselors solicit private information from clients only when it is beneficial to the counseling process.

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duty to warn and duty to protect

Back 25

Mental health professionals, have a double professional responsibility: to protect other people from ptoentialy dangerous clients and to protect clients from themselves.

Front 26

Therapist liability from failing to warn public from violents clients

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1-failing to diagnose or predict dangerousness 2- failing to warn potential victims of violent behavior 3 =failing to commit dangerous individuals or 4- premature discharging dangerous clients from a hospital

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tarasoff: failing to act

Back 27

When a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. The discharge of this duty may require the therapist to take one or more of various steps, depending upon the nature of the case. Thus it may call for him to warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps are reasonably necessary under the circumstances.

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Tarasoff

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Un der the Tarasoff decision, the therapist must first accurately diagnose the cleint's tendency to behave in dangerous ways toward others. This first duty is judged by the standard of prosessional negligence.

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The Bradley case- Negligenttly realse a dongelient client

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A therapist has a duty to take reasonable care to prevent a potentially dangerous patient from inflicting harm.

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Jablonsky Case: duty to commit a dangerous individual.

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Therapist failed to record and pass on information to the evaluating psychiatist, failed to obtain a prior medical record indicating violent behavior, and failed to warn the patient's common law spouse hat her husand was dangerous.

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The Hedlund case

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it extends the duty to warn to anyone who might be near the intended victim and who might also be in danger

Front 32

The Jafee case

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The supereme court ruled that communications between licensed psychotherapists and their clients are privileged and therefore protected from forced disclosure in cases arising under federal law. This case represented a victory for mental health organizastions because it extends the confidentiality privilige.

Front 33

Guidelines with dangerous and suicidal client

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Therapists have ethical and legal obligations to prevent their clients from physically harming themselves or others. If you believe a client is dangerous, you must use reasonable and conscientious effort in taking decisive actions to both protect and warn the potential victim of your client's violence.

Front 34

Guidelines with dangerous and suicidal client

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examine your informed consent document. Is it clear in terms of the forfeiture of privilege becasue of a threat of violence to self or othrs?
Know how to contact the legal counsel fo your professional organizatin. Familiarize yourself with professional who are experienced in dealing with violence. Such experts can be located through your pfofessional orgaznizatio.
if there is any hing of violence in the client's history, requst clinical record fom previous therapist, if they exist.
take at leeast one whorkshop in teh assessment and management of dangerous clients. Determine that the limits of your professional liability insurance are adequate.

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Guidelines with dangerous and suicidal client

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Become educated in risk assessment, stay current withd evelopment in the field, and be conversant with the relevant laws.
For cases that raise particular concern about violence, consider intensification of treatment or hospitalization. seek consultation from expereinced colleagues or cuonsultant.
Recor the source, content, and date of significant information on risk and the rationale and dates of all actions taken to prevent violence.
Develop policy statements and feasible guidelines for handling risk, and subject these guidelines to clinical and legal review.