Recordkeeing Requirements for the Counseling Professional. The Musts, The Shoulds, and The Definitely Nots!

Transcription

1 Recordkeeing Requirements for the Counseling Professional The Musts, The Shoulds, and The Definitely Nots!

2 Laura Diamond Carls, McDonald & Dalrymple, LLP (512)

3 CAVEAT: These materials have been prepared for the information and general use by attendees of this course. To the best of my knowledge, the information contained in this presentation is accurate. I am reasonably sure that my citations are correct. However, neither the text of this presentation, nor any remarks made during the lecture are intended for use as legal advice. Please consult an attorney who specializes in these areas for legal advice on all real or potential problems. Further, the opinions expressed in this paper and during the lecture are my own, and are not necessarily the opinions of the Texas Counseling Association.

4 Where do we find the rules? LPC LMFT LCSW LCDC

5 Additional useful information on the Boards' websites Renewal Applications Forms Links to Texas and National Associations Enforcement Actions Contact Information for the Board

6 THE MUSTS What records do the rules require?

7 MUST: LPC Rule (q) For each client, licensee shall keep accurate records of Intake assessment Dates of treatment Principal treatment methods Progress notes Treatment plan Billing information

8 LPC Rule (t)(6) Prior to the commencement of counseling services to a minor client who is named in a custody agreement or court order, a licensee shall obtain and review a current copy of the custody agreement or court order, as well as any applicable part of the divorce decree. A licensee shall maintain these documents in the client's record.

9 MUST: LMFT Rule (e) A licensee shall keep accurate records of therapeutic services to include, but not be limited to dates of services types of services progress or case notes billing information

10 MUST: LCSW Rule The licensee shall keep accurate and legible records of the dates of services types of services progress or case notes intake assessment treatment plan billing information*

11 MUST: LCDC Rule (f)(2) Applies to all LCDCs A Licensee shall maintain complete, accurate, and appropriate documentation of services provided

12 MUST: LCDC Rule (a)(1) In addition, LCDCs in private practice The client record shall include: client identifying information assessment results, including a statement of the client's problems and/or diagnosis plan of care

13 MUST: LCDC Rule (a)(1), con t The client record shall include: documentation of all services provided, including date, duration, and method of delivery a description of the client's status at the time services are discontinued

14 MUST: LCDC Rule (2) The counselor shall maintain a record of all charges billed and all payments received. (3) All entries shall be permanent, legible, accurate, and completed in a timely manner. (4) All documents and entries shall be dated and authenticated. Authentication of electronic records shall be by a digital authentication key. (5) When it is necessary to correct a record, the error shall be marked through with a single line, dated, and initialed by the counselor.

15 MUST: Client Record Retention LPC Rule (r) Minimum of 5 years from date of last contact with client LMFT Rule (e), LCSW Rule (4), and LCDC Rule (a)(9) Minimum of 5 years for an adult client and 5 years beyond the age of 18 for a minor * Per, Texas HIPAA, must keep records for 6 years!

16 MUST: Supervision Records LPC Rule (d) A board approved supervisor shall maintain and sign a record(s) to document the date of each supervision conference and document the LPC Intern's total number of hours of supervised experience accumulated up to the date of the conference. The record shall reflect the approved site where the hours were accrued and the content of the supervision.

17 MUST: Supervision Records LMFT Rule (e) A board-approved supervisor shall maintain and sign a record(s) to document the date of each supervision conference and document the LMFT Associate's total number of hours of supervised experience accumulated up to the date of the conference.

18 SHOULD: Supervision Records Supervision file should also contain copies of: Supervisory Agreement Forms Intern s license Intern s resume Employment documents job posting/description, application, background and reference checks, confidentiality agreement, payroll records

19 THE SHOULDS What records should be kept? And how should we keep the required records?

20 SHOULD: Progress Notes But, what should a progress note include?

21 SHOULD: Treatment Plan But, what should a treatment plan contain?

22 Templates The Pros: A good tool Can help document required elements Can be customized to your practice The Cons: Use as a guide the minimum can always document more Blank or incomplete sections

23 SHOULD Maintain documentation of compliance with pre-service informational requirements Anything you are required to inform your client about in writing before providing services.

24 For example: Prior to services inform in writing: LPC Rule (e)(8) and LCSW Rule (4) Plan for the custody and control of the client s records should licensee die, become incapacitated, or cease offering services

25 For example: Prior to services inform in writing: LPC Rule (e)(4) limits on confidentiality LCDC Rule (l) rights regarding confidentiality

26 Another example: Prior to services inform in writing: LPC Rule (e)(1) fees and arrangements for payment LCDC Rule (l) fee schedule and establish financial arrangements with a client.

27 SHOULD: Billing Records LPC Rule General Ethical Requirements (f) bill clients for only services actually rendered LCDC Rule Professional and Ethical Standards (l) counselor shall not charge exorbitant or unreasonable fees

28 SHOULD Maintain documentation of required reporting Abuse or neglect of minors Abuse, neglect & exploitation of elderly Abuse, neglect, illegal, unprofessional or unethical conduct by treatment facility Sexual exploitation by another mental health provider

29 THE DEFINITELY NOTS! What your records should never contain. How not to handle records.

30 Text Messages Use sparingly, if ever, and only for scheduling! Are part of the client s chart do you know how to print a text message?

31 s Not recommended! Use only for scheduling Part of the client s record What if the client s personal information?

32 Responding to Requests for Records

33 From the Board MUST: Respond to Board s request provide everything! Cooperate with investigation SHOULD: Provide organized, page numbered chart Provide color copies, if necessary Type notes, if necessary DEFINITELY NOT: Ignore the request Remove or alter documents

34 From a Client MUST: Must provide copy (H&SC Ch ) May charge for the copy SHOULD: Keep a record of the request and what was provided DEFINITELY NOT: Ignore the request

35 Consequences: Disciplinary Actions Related to Recordkeeping

36 Administrative Penalty LPC failure to provide/complete required supervisory agreement form; failure to keep supervision records ($500) LPC failure to respond to the Board regarding a complaint ($1,000) LPC failure to release client records to client s father ($2,000) LMFT failure to comply with H&SC Ch. 611 regarding release of records ($250)

37 Reprimand LPC failure to retain records and inability to comply with H&SC 611 (+ $500 administrative penalty) LPC dual relationship and releasing client s records without consent LCSW failure to keep adequate records and records contained billing inaccuracies LPC failure to keep accurate records

38 Probated Suspension LPC failure to maintain professional boundaries, dual relationship with a client and failure to keep accurate client records (1 yr) LPC failure to set/maintain professional boundaries, dual relationship with client, failure to respond to Department Investigator, and failure to provide documents at Board s request (2 yrs) LCSW failure to keep adequate patient records (1 yr)

39 Revocation LMFT failure to set and maintain professional boundaries by entering into a dual relationship with a client, failure to take reasonable precautions to protect minor client from physical and emotional trauma, failure to offer services within professional competency, failure to keep accurate client records and failure to timely respond in writing to a Board request regarding client records.

40 Recordkeeping Matters! The Rules tell you what Must be recorded Common sense and experience tell you what Should (and Definitely Not!) be recorded Sources for support Board website Colleagues Legal Counsel

41 Laura Diamond Carls, McDonald & Dalrymple, LLP (512)