• are any physical recording made of info related to a clr's professional practice
• kinds: clinical case notes, clt's admin records: appt books, billing, paymt accts, correspondence copies, intake forms, clt's documents, audio & video taped session recordings
• other kinds: clt's computer logs, phone bill w/clt's # listed, computerized recording of clt in office bldg, parking lot, etc

• clg records are created for several reasons which to protect both clt & clr
• ACA code A1b states clrs are to maintain records necessary for rendering professional services to clts
• ethically this purpose is assist clrs in providing the best clg services/care to clts

The Clinical case notes will

• allow clr to review progress towards goals,
• to know when important decisions & actions were taken
• to maintain overall perspective on content & process of clg relationship
• benefit to clt - they allow clr to sum each interaction w/clt & record future plans
• allows clrs to stay on track by documenting tx plan undertaken & why
• helpful to clrs when we work to maintain a clear conceptualization of clg goals & their progress
• good records can assist in measuring clts growth & changes or none
• can use notes to reference any significant turning points, successes, failures in working w/clts

• clinical notes become important when clt resume clg after an extended break
• continuity of care - when a clt is referred to another clr or healthcare provider, records are transferred as well - it informs other professionals of the clt's condition
• notes s/b written to inform referred clr what did or did not happen
• clrs document the steps taken in an emergency or critical situation, records serve as evidence if suited

A.1.b. Records

• Counselors maintain records necessary for rendering professional services to their clients and as required by laws, regulations, or agency or institution procedures.
• Counselors include sufficient and timely documentation in their client records to facilitate the delivery and continuity of needed services.
• Counselors take reasonable steps to ensure that documentation in records accurately reflects client progress and services provided.
• If errors are made in client records, counselors take steps to properly note the correction of such errors according to agency or institutional policies

B.6.a. Confidentiality of Records

• Counselors ensure that records are kept in a secure location and that only authorized persons have access to records.
• Clrs are responsible for securing the safety & confidentiality  of any clg  records they create, maintain, transfer, destroy -Txbk

• Put the files away when leaving the office in a secure location
• use a password in order to access computerized notes. always close a secure file when leaving the room

B.6.b. Permission to Records

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

B.6.c. Permission to Observe

• Counselors obtain permission from clients prior to observing counseling sessions, reviewing session transcripts, or viewing recordings of sessions with supervisors, faculty, peers, or others within the training environment

B.6.d. Client Access

• 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.

B.6.e. Assistance With Records

• When clients request access to their records, counselors provide assistance and consultation in interpreting counseling records.

B.6.f. Disclosure or Transfer

• Unless exceptions to confidentiality exist, counselors obtain written permission from clients to disclose or transfer records to legitimate third parties. Steps are taken to ensure that receivers of counseling records are sensitive to their confidential nature.(See A.3., E.4.)

B.6.g. Storage and Disposal After Termination

• Counselors store records following termination of services to ensure reasonable future access, maintain records in accordance with state and federal statutes governing records, and dispose of client records and other sensitive materials in a manner that protects client confidentiality. When records are of an artistic nature, counselors obtain client (or guardian) consent with regards to handling of such records or documents. (See A.1.b.)

B.6.h. Reasonable Precautions

• Counselors take reasonable precautions to protect client confidentiality in the event of the counselor’s termination of practice, incapacity, or death. (See C.2.h.)

• legal principles indicate the content on records for the clt is the property of the clt People v Cohen 1979
• common law does not require clrs to obtain written permission prior to giving records to third parties
• however some federal laws, state statues, agencies polices require written permission - oral permission appears to be acceptable as well
• there are no common law, federal or state statues that require clrs to keep clinical case notes

ACA code A1b

• Counselors maintain records necessary for rendering professional services to their clients and as required by laws, regulations, or agency or institution procedures.
• Counselors include sufficient and timely documentation in their client records to facilitate the delivery and continuity of needed services.
• Counselors take reasonable steps to ensure that documentation in records accurately reflects client progress and services provided.
• If errors are made in client records, counselors take steps to properly note the correction of such errors according to agency or institutional policies.

• Clrs are responsible to hold up confidentiality & privilege for oral communication regarding the privacy of clts as well

• ACA codes allow clrs to determine which types of clinical case notes are needed to render professional services
• it is best the clr decide the kind of records they need base on their position & the kind of clinical case notes they need to create in order to be effective clrs
• admin records, recordings, clinical case notes

• include appt books, billing & paymt accts, correspondence copies, signed inform consent documents, clt's release of info forms, intake forms, or other routine papers created due to clg services
• business records that reveal the identity of persons/clts who have had contact with the agency must be treated as confidential & must be protected in the same way as clinical case notes

• recording are used in session with clts for review of their behavior & interactions
• if given to clts, clr must ensure the clt will secure or erase the recordings;
• it is suggested to have clts sign a form stating they understand the potential problems that might arise
• ACA code A6b clr to get permission from clt prior to recording & ensure clt understand the use of these recordings & who will have access to them

• report the tape lost to her supervisor
• label future tapes in a way that only student & supervisor will recognize
• do not write the clt's name or info on the tape

• grad students are responsible for turning in the videotapes to their supervisor
• retrieving them once reviewed & erasing them
• clrs must erase tapes after usage
• clrs using current technology must take care to safe guard clt's privacy & be carefully in storing, disposing recordings

• they contain specific clt info, clrs' clinical impression of clts, sensitive/personal info about clts
• notes will be viewed by others, not taking notes is unprofessional practice-it safeguard against legal defense & having to reveal clt's info
• clrs has to assume their notes will be read-must be careful what to document
• clt has legal right to read & obtain copies of your notes, clts can request transfer of clinical notes to referred clr/provider
• clts can subpoena your notes when involved in litigation; others can too over the objection of the clt & even when they are privileged
• deceased relatives have right to access notes

• take notes during or after session

method - SOAP

• subjective info reported by the clt
• objective results of the clr's tests, assessmts given
• assessment the clr's impressions generated by data
• plan dx & tx plan w/any modifications

method DAP

• data objective description of what occurred in session
• assessment clr's impression
• plan clr's intended goals/plan for future sessions

• document all interactions with clt both in session & outside the sessions
• document both clr & clt's behavior, any emergency situation, any decisions made with clt or as a result of clt & why
• clr to write notes in a way that others may be able to understand

• clr to document refusal of clt to see the CCN or records & why code B6d
• HIPAA states clt shouldhave access to their records except if content will cause harm to clt
• clr may discourage clt from seeing the notes or request to provide a summary-copies provided must include clt info only

HIPAA

• known as the privacy rule went in affect 4/2003
• clr must give clts a clear written explanation of how clrs use, keep, disclose their health info.
• clt must have access. clr must have written privacy procedures include who has access to protected info - available to clts
• clts must be given a way to make inquiries about their records or make complaints
• clrs must get clt's consent to release info for tx, paymt, etc
• disclosures w/o consent/permission allowed - quality assurance activities, research, judicial or admin hearings, limited legal proceedings, emergency
• clrs can share health info with other family members if clt objects to proposed tx/care-clr who wish to use this rule must info clt prior to clg
• when clt request transfer te full record must be transferred
• offices/agencies must assign a privacy officer who will train others on how to handle confidential info
• under HIPAA, no one but clr has access to CCN. rationale such notes are not apart of the record. clt must make specific request to have the CCN transferred to third party
• violation of HIPAA fines - is federal & override state laws 

Family Educational Rights & Privacy Act FERPA

• known as Buckley Amendment affect all public, private, parochial educational institutions
• violation is loss of federal funding & individuals cannot sue
• school health records are exempt from HIPAA rule, communication betw schools & healthcare provider is subject to HIPAA rule
• FERPA states that parents of minor students, 18yo & older students, those in college have 2 rights:
• #1to inspect & review their education records & to challenge the contents to ensure the records are not inaccurate or misleading
• #2 to have their written permission to obtain copies or transfer to third party
• parents of minor or dependent students may obtain copies w/o student's consent
• school clr case notes s/b filed separately -they are exempt from inspection & review. tx records by MD, psychologist, psychiatrist, etc are exempt as well-notes are off limits to parents,students
• schools do not need parental permission to release school records to other schools- when transferred, parents must be notified & given copies if they wish to obtain
• school must notify parents in advance if records are subpoena & to be released
• in emergency situation-an amendment to act ha given permission to release private info w/o parental/student consent-info must be necessary to protect the health or safety of the student or other persons
• any disciplinary actions/proceedings taken against a perpetrator, the school may release info to victim

Federally funded Substance Abuse Programs

• federal statue states that records kept by any facility that is conducted, regulated, or directly or indirectly assisted by federal govt are confidential
• disclosure of clts records receiving substance abuse tx (education, training, tx, rehab, research) is permitted only in few circumstances
• exceptions would be: #1 when clt has given written permission, #2 medical emergencies, #3 audits/evaluations, #4 to avert substantial risk of death or serious harm-if court order is secured
• records cannot be used for criminal investigations or charges-however a clr direct observation (assume CCN) are not record & can be used in criminal proceedings against clts
• same law permits mandatory reporting of suspected child abuse & neglect under state laws; permits exchange of records betw military & DVA
• violation of this law can lead to criminal charges & fines. clts may file criminal complaint against clrs in federally SAPs who violate their right to privacy but they cannot file civil lawsuits for damages

Other Federal Statues

• federal statues prohibit or limit disclosure of clg records for clts who are serviced in federally assisted programs
• #1 runaways &homeless youth 42USCA 5731
• #2 individuals with sexually transmitted diseases 42UBCA 247c,d,5
• #3 voluntary clts in federal drug abuse & dependence programs 42USCA 260d
• #4 older persons 42USCA 3026d, 3027f1
• #5 victims of violence against women 42USCA 14011b5
• on other hand privacy can be limited-a federal statue specifically denies confidentiality to individuals who are examined by MD in civil commitment proceedings due to drug abuse 42USCA 3420

• ACA code states records must be secured safely B6a; agencies should have written policies on record-keeping
• clrs CCN s/b secured & locked away in file drawers; office should have a record manager-would be responsible for handling, securing, chk in/out of files, elimination
• records are kept for a # of yrs -5-7; clrs should adhere to agency policies, accredited organizations/bodies record-keeping policies
• records s/b kept for extended period if its believe that they will be subpoenaed in the future; if personnel destroy said records, they could be charged with a crime

• ACA code B6f requires clr obtain clt's permission (written) prior to transferring records. clr should transfers copies not the originals
• clr should transfer only the items requested by the clt; if other professionals info is on file, clr is not permitted to include those notes in the transfer. clt has to request the info from the professionals who created those files
• the written permission s/b included in clt's file & the mode of transfer via mail

• clr should info the person she has to discuss his with her supervisor to determine how to respond. she should tell him not to wait the file may follow at a later date
• clr to notify her supervisor & ensure the validity of the subpoena & request legal advice
• if no attorney was provided

• court orders are issued in hearings or trials by judges -written. if not obeyed, judge can sanction by fines, imprisonmt

Discoveery in Litigation

• lawyers are officers of the court & can issue a court order
• in discovery attorney has the right to ask for & receive info relevant yo their case before case is tried-each side should know all info that will be entered in before trial begins
• clrs are asked to respond in writing to questions, or provide copies of records, or come to office for depositions & witness can be asked to testify

Validity of subpoenas

• clrs must consult supervisor or attorney-must discuss privilege issue with attorney & comply with either advice

Interrogatories

• written questions included in subpoenas-they must be answered consult attorney with questions & answers-discuss responses with attorney

Appearances at proceedings

• consult attorney; clrs should be accompanied by attorney. if clr refuse to answer any questions at deposition, attorney will file order to show cause & ask that clr appears before a judge to explain your refusal-judge can hold you in contempt

Testimony under oath

• clr will have to testify under oath to tell the truth, any false statemts are considered perjury

Turning over records

• clr can submit summaries or copies of notes
• do not forward copies of other professional reports about the clt to the court
• clts for clr being subpoenaed will consult with their attorney to assert privilege or have subpoena squashed
• if clts are not available, the clr's attorney should assert privilege & take steps to avoid compliance with subpoenas