Term
| What are records in counseling? |
|
Definition
information related to counselor's practice.
ex: clinical case notes, appointment books, billing, intake forms, recordings, telephone bills. All must be considered part of client's right to privacy |
|
|
Term
| What are the main purposes of record keeping in counseling? |
|
Definition
| TWO MAIN REASONS: to provide best service to client (ethical reason); and to protect themselves (legal reason) |
|
|
Term
| How do records benefit the client? |
|
Definition
Allows cnslr to summarize and plan future sessions.
Documents what trmnts used.
Measures growth and change.
Helps when client RESUMES trtmnt.
Provides continuity of care. |
|
|
Term
| What should be included in notes? |
|
Definition
Document any steps in emergncy or crisis.
Goals, strategies, progress made. |
|
|
Term
| What to consider when making notes? |
|
Definition
| Clarity: helps you as counselor and future caregiver. Consider motivation for writing ntes, who will read them. |
|
|
Term
| What are the ethical standards for record keeping |
|
Definition
Thre are 8 standards for record keeping:
1)keep records as asked by law,agency or institution.2)keep records secure3)obtain written consent before recording/taping session 4)provide clients access unless harmful or contain info about other clients 5)obtain written permission to transfer any records unless exception to confidenty. 6)keeping/destroying records 7)reasonably protect client's confidentiality if they die/incapacitate 8)3rd party payment info must be part of consent with client |
|
|
Term
| Who is responsible for taking steps to ensure that receivers of counseling records are sensitive to the confidential nature of the records? |
|
Definition
| The counselor! This means the counselor must include a cover letter alerting receiver to confidential nature of material, incldng info that it cannot be transferred to 3rd party |
|
|
Term
| When should a counselor destroy a client's records? |
|
Definition
| When it is clear that person will no longer receive services. Best practice is to receive written release from client if possible when records are of an 'artistic' nature: poem, drawing. |
|
|
Term
| To whom do the contents of a counseling record belong? |
|
Definition
| The client, even though the paper and file belong to counselor. |
|
|
Term
| What is more stringent ACA standard regarding record transfer or common law? |
|
Definition
| ACA standard. It requires written permission to transfer a client's records.Common law does not.Some states and agencies have law similar to ACA |
|
|
Term
| What are the legal requirements for keeping clinical case notes? |
|
Definition
| There is no common law standard. HOWEVR, ACA code of ethics says ethical counselors keep case notes that document services rendered to clients. |
|
|
Term
| What are legally related reasons counselors keep notes? |
|
Definition
| Billing, expense, income for tax purposes. Also attorneys advise counselors to document everything they do as protection |
|
|
Term
| What are the three main types of records counselors keep? |
|
Definition
| administrative records, recordings and clinical case notes |
|
|
Term
| What are administrative records and why are they confidential? |
|
Definition
| Type depends on setting. Anything not recordings or CCN. ex: appt. books, signed consent forms, intake forms, routine paperwork. Business records can reveal identity of clients |
|
|
Term
| What are the issues regarding recordings of clients or sessions? |
|
Definition
| Counselor must emphasize with client: a recrding compromises privacy; recording could be subpoenaed; a consent form must be obtained prior to recording. |
|
|
Term
| What is the best practices for handling recordings of sessions for educational purposes? |
|
Definition
| Students use for their purpose, then destroy them. Counselors can use for supervision then destroy. |
|
|
Term
| Which kinds of records are most concerning to both counselor and client? |
|
Definition
|
|
Term
| What is a serious problem regarding counselors ideas around Clinical case notes? |
|
Definition
| Some counselors regard them as personal notes to themselves. NOT TRUE |
|
|
Term
| What are consequences for counselors who do not keep notes? (3) |
|
Definition
| 1)could be accused of unprofessional practice 2)absence of notes could not keep a counselor from being asked to reveal information 3)Notes help counselor function as a professional. |
|
|
Term
| How should notes be written by a counselor? What should counselors remember as they write them? |
|
Definition
| As if they will be read; be cautious in making notes; clients have right to read notes and demand transfer of notes, clients can subpoena notes, clinical notes can sometimes be published in media. |
|
|
Term
| What are the two basic reasons to keep notes? |
|
Definition
| 1)provide service to client 2) protect counselor/document decisions |
|
|
Term
| When should notes be taken? What should be recorded? |
|
Definition
Right after session or during session.
Document objective information separate from clinical impressions. |
|
|
Term
| What is one way to record clinical notes? |
|
Definition
SOAP
s:subjective info reported by client
O: objective/results of tests,assessment
A: assessment-counslr impressions
P: Plans/diagnosis, treatment |
|
|
Term
| What are critical situations to document? |
|
Definition
| 1)danger to self or others.2)action taken 3)people consulted in situation 4)recording words used 5)any situation that could be reviewed later by ethics panel. 6)one involving legal actions |
|
|
Term
| When do counselors provide client access to records? |
|
Definition
| When client asks unless there is EVIDENCE that it would harm; then can limit access. |
|
|
Term
| What can be done if you (counselor) think records would harm client? |
|
Definition
| explain why it might not be helpful; suggest using a summary of the notes rather than all; explain that ntes taken for counselor and might not be helpful. |
|
|
Term
| HIPAA and counseling: who or what are affected? |
|
Definition
*any agency that transmits health care information
*any records that identify an individual's health care info. |
|
|
Term
| Regarding HIPPA, what info should counselors give clients? |
|
Definition
| Clear, written explanation of how health care info kept and used. Written notice that client has right to info. Written notice regarding who has access to health records. Written notice about how to access records or make requests. |
|
|
Term
| What does a counselor need in order to release information for treatment or payment or health care purposes? |
|
Definition
| Written, uncoerced agreement of client. |
|
|
Term
| What is an exception to HIPPAA disclosure that could help counselors and clients who need family support? |
|
Definition
| There is an exception that says a client can give oral permission for information to be given to a family member. Supported in ACA ethics. |
|
|
Term
| How much client information should be released when it is permitted and asked for? |
|
Definition
| Only the most minimal amount (essential) of information to accomplish the purpose. Supported by HIPPA and ACA Codes |
|
|
Term
| Who handles HIPPA rules in a counseling office? |
|
Definition
| A designated privacy officer, sometimes it is the counselor who is responsible for training other employees. |
|
|
Term
| What are the penalties for violating HIPAA? |
|
Definition
| $100 per incident up to $25, 000 |
|
|
Term
| What are the HIPPAA laws regarding clinical case notes? |
|
Definition
| HIPPA calls them psychotherapy notes. Special standard of protection required. Clients must give specific written consent for their transfer. |
|
|
Term
| What agencies are affected by FERPA or Buckley ammendment? |
|
Definition
| Any public educational institution that receives federal funding. Penalty for violating is loss of all federal funds. |
|
|
Term
| How do FERPA and HIPPA interact? |
|
Definition
| Some health info affected by FERPA/others by HIPPA. If health care part of school, HIPPA rules follow. If health info in school record, FERPA |
|
|
Term
| Who has rights to ed. records under FERPA? |
|
Definition
| Parents have rights to records until child is 18 and rights to have records transferred to a 3rd party. Rights continue as long as student receives more than 50% of support from parents. |
|
|
Term
| When are school counseling notes exempt? |
|
Definition
| When they are kept separate from any educational files or records. |
|
|
Term
| Do schools have to obtain permission to transfer records to another school? |
|
Definition
| No, as long as the student intends to register there. However parents must be notified of the transfer and given records if asked. |
|
|
Term
| Are there exceptions to FERPA? |
|
Definition
| Information can be released if the emergency is deemed harmful to the student or safety of others. Also schools can give info regarding a specific perpetrator to an alleged victim of a violent crime. Discipnary actions can be included in ed. record. |
|
|
Term
| Under FERPA can counselors use oral permission to transfer records? |
|
Definition
| No, it must always be written. Stronger than common law. |
|
|
Term
| What are standards regarding federally funded substance abuse programs? |
|
Definition
| All records confidential if a facility receives any federal funds. Records cannot even be used in criminal proceedings. |
|
|
Term
| Are there exceptions to federal statutes around substance abuse treatment records? |
|
Definition
| There are four: prior written consent by client; medical emergency; audits or evaluations and to avert risk fo death if a court order is obtained. |
|
|
Term
| What is the consequence for release of information regrading substance abuse treatment? |
|
Definition
| CRIMINAL CHARGES AND A FINE. |
|
|
Term
| What special categories of clients have federal statutes protecting the release of their counseling information? |
|
Definition
| runaway and homeless youth; individuals with STIs; voluntary clients in rehab; and, victims of domestic violence |
|
|
Term
| What strategies do counselors use to protect client information regarding records? |
|
Definition
| Secure locked location, limited access, designated records manager, written polices regarding records, records returned to files NOT unattended. |
|
|
Term
| What are statutes regarding destroying or maintaining certain client records? |
|
Definition
| Varies by state, agency and type of records. |
|
|
Term
| Why might records need to be destroyed periodically? |
|
Definition
| They are expensive to maintain; information could be compromised. Agencies need policies regarding file destruction and follow it unless reason to believe records needed later. |
|
|
Term
| When and how should a counselor transfer a client's records when requested? |
|
Definition
| Specific written permission regarding transfer and who intended recipient will be, including specific documents to be sent. ONLY COPIES NEVER ORIGINALS |
|
|
Term
|
Definition
| Court document used often in discovery or pretrial process. |
|
|
