Clinical Supervision Ethics: Clinical Records

This program is approved for 6 continuing education hours by:
The California Board of Behavioral Sciences # PCE 3457
The California Board of Registered Nursing # CEP 14462
The National Association of Social Workers (NASW) # 886463870-2166
The Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling #50-14000
Texas Board of Examiners of Marriage and Family Therapists # 628
Texas State Board of Examiners of Professional Counselors #1646
The Texas Board of Social Worker Examiners # 5547
The National Board for Certified Counselors (NBCC) # 6412

At the end of this course participants will be able to:

1. Identify the purposes of well-kept clinical files.
2. Clarify the responsibility of the Supervisor and Supervisee in maintaining clinical records.
3. List at least eight areas that belong in the therapy record.
4. Identify what forms need to be included to document informed consent.
5. Identify the rights clients have under HIPPA and its exceptions to confidentiality.

INTRODUCTION

Therapy records involve a number of demands and constraints. Some of the demands are considering ethical standards, legal requirements, situational contexts and more. As a supervisor, one of your jobs is to aid your supervisees to keep proper records. You may also have some input into agency policies.

Some of the record keeping is required by state and/or federal laws. These will be addressed as you continue through this program. You'll need to combine your training and education, as well as a multitude of skills to recognize pertinent issues and to resolve problems that you run into.

Ten Sixteen Recovery Network (n.d.) gives a good overall picture when it tells its clients that the clinical file serves as a:

• Basis for planning the client's care and treatment
• Means of communicating among clinical staff who contribute to your care
• Legal document describing the care the client received
• Means by which the client or a third party payer can verify that she actually received the services billed for.
• Tool for education (i.e., interns)
• Source of information for the public health officials charged with improving the health of the regions they serve
• Tool to assess the appropriateness and quality of care given
• Basis for accrediting organizations, licensing, and third party audits to evaluate the treatment.

Because of the nature of the clinical file, also called the therapy records, it's very important to be sure they're used only for proper purposes and in proper situations. It's part of your job as supervisor to aid in this protection of the records.

The American Psychological Association publishes guidelines for keeping records. Thirteen guidelines are given (American Psychological Association, 2007). Although they relate specifically to psychologists, they're applicable to any mental health practitioner and supervisor. The records are not necessarily the sole responsibility of these folks, but a collective responsibility of them and their agency. However, to bring home the importance for you, as a supervisor, to be aware of these guidelines, the original APA wording of "psychologist" has been changed to "supervisor" and some adaptations have been made to fit your role:

• Responsibility for Records: Supervisors generally have responsibility for overseeing the maintenance and retention of their supervisees' records.
• Content of Records: A supervisor strives to be sure the supervisees maintain accurate, current, and pertinent records of professional services as appropriate to the circumstances and as may be required by the supervisor’s jurisdiction. Records include information such as the nature, delivery, progress, and results of psychological services, and related fees.
• Confidentiality of Records: The supervisor takes reasonable steps to establish and maintain the confidentiality of information arising from service delivery.
• Disclosure of Record Keeping Procedures: When appropriate, supervisors either inform clients or guide their supervisees to inform them of the nature and extent of record keeping procedures (including a statement on the limitations of confidentiality of the records).
• Maintenance of Records: The supervisor strives to be sure the records are properly organized and maintained to ensure their accuracy and to facilitate their use by the supervisor, the supervisee and others with legitimate access to them.
• Security: The supervisor takes appropriate steps to protect records from unauthorized access, damage, and destruction.
• Retention of Records: The supervisor strives to be aware of applicable laws and regulations and to retain records for the period required by legal, regulatory, institutional, and ethical requirements and to keep the supervisees apprised of them.
• Preserving the Context of Records: The supervisor strives to aid the supervisees to be attentive to the situational context in which records are created and how that context may influence the content of those records.
• Electronic Records: Electronic records, like paper records, should be created and maintained in a way that is designed to protect their security, integrity, confidentiality, and appropriate access, as well as their compliance with applicable legal and ethical requirements.
• Record Keeping in Organizational Settings: Supervisors working in organizational settings (e.g., hospitals, schools, community agencies, prisons) strive to follow and help supervisees to follow the record keeping policies and procedures of the organization as well as the Ethics Code of their discipline.
• Multiple Client Records: The supervisor trains the supervisees to carefully consider documentation procedures when conducting couple, family, or group therapy in order to respect the privacy and confidentiality of all parties.
• Financial Records: The supervisor strives to ensure accuracy of financial records. Even if this is not the normal domain of the supervisor, he will want to keep tabs on it.
• Disposition of Records: The supervisor plans for transfer of records to ensure continuity of treatment and appropriate access to records when the supervisee and/or the supervisor is no longer in direct control, and in planning for record disposal, the supervisor endeavors to employ methods that preserve confidentiality and prevent recovery.

There are a number of ways the information and requirements regarding records could be presented. It was decided to use these 13 guidelines as the framework for the more details discussions of significant points.