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Katie Peterson
[email protected]
1120
COUNSELORS RESPONSIBILITY WITH
CLIENT RECORDS
By Katie Peterson
Is my counselor responsible? A counselor’s responsibility to keep client records is a very
important part of maintaining the professional standard. Our book says that the main reason why
adequate records should be kept is to provide high-quality services as well as maintain a
cohesive process in the event of other counselors being involved with care. In the clinical
prospective record keeping is also very important from a legal and managed care perspective.
Record keeping can be done in different formats typed or hand written. The confidentiality piece
remains the same no matter what form notes are done in, although many record are taken and
stored electronically, the computer being used could be compromised by the risk of faulty
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computer security programs. Surprisingly despite the possibility of a breach in confidentiality,
electronic records compared favorably with manual records and there was no difference besides
electronic records were easier to understand. (National Center for Biotechnology Information,)
Confidentiality is the core of effective psychotherapy. Clients must trust in their therapist to
respect their records and protect the intimate information. Counselors must discern between
public safety and confidentiality. Determining the balance between the two is rarely cut and dry.
When “imminent danger” to others or to the client itself is evident, the counselor has an ethical
and legal obligation to disclose information needed. The counselor typically follows four
conflicting principals to determine the amount of risk to others, if it outweighs the rights of an
individual.
Once a counselor documents a high risk comment such as “could be suicidal or major risk to
community, the counselor must then write what action has been taken to prevent the act from
happening. Legal obligations are imposed on the counselor once a note is written about possible
suicide or homicide is documented. If a counselor has suspicions of any type of abuse they
should contact appropriate law enforcement agency. In tough cases like the types listed above, it
is good practice to as a co-worker or supervisor for their professional judgment on a specific case
before making any major decisions. (Gerald Corey, 2011)
One person cannot have all of the answers on how to keep client notes; there are many
factors in writing notes. Many people in the clinical field use the SOAP method, but my agency
uses SOTAP, it is on the same lines except for more in-depth explaining what you did for
treatment. The acronym stands for Subjective, Objective, Treatment, Assessment and Plan.
When working with the county, state or federal, precise record keeping is required. Each setting
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will determine the detail you put in your notes, along with your own preference. My agency also
requires buzz words such as active listening, relapse triggers, creative, honest positive and light
hearted. These key phrases help the notes to have a stronger more positive spin on your notes.
There are a number of people who may be reading summary notes and the problem of
indecisive wording, using objective wording will help to write clear notes. It is very important to
as yourself how many different ways could this phrase be interpreted? If the note was read by the
client, would it have a negative effect on the client counselor relationship? Different third party
payers may require certain regulations pertaining to record keeping.
A good rule of thumb to go by is always do your notes within 48 hours of meeting with
client, no longer that that or clients and thoughts may not be very accurate. The records should
be accurate, coherent, concise, and timely while their confidentiality is protected.
To begin with the Wisconsin Administrative Code (HFS 75.03, 2011) (8) Patient case records
(d) states “The case record format shall provide for consistency and facilitate information
retrieval.” This statement seems simple enough and is the staple of record keeping. Any client
who begins treatment has certain records that will be kept in regards to their case. These
records may provide the client, counselor, clinical supervisor, staff members, mental health
providers, and medical provider’s any and all relevant information to a client’s case. If any one
of these individuals needs information, they should be able to access in their file/chart.
Client charts should be maintained in a secure room that is locked, safe or other similar
storage when not in use. (Services) (I couldn’t find a policy on being locked in WI) I do believe
that is a per individual agency decision as to what they’re in and where. Recently there are
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newer methods of electronic storage of records which I believe will be an efficient way for
treatment team members to correspond about cases.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPPPA) are
guidelines for electronic use of record keeping. HIPPA is balanced so that it permits the
disclosure of personal health information needed for patient care and other important
purposes but protects and gives an array of rights to the client. The Security Rule within HIPPA
specifies a series of administrative, physical and technical safeguards for covered entities to use
to assure the confidentiality, integrity and availability of electronic protected health
information (Office for Civil Rights, 2011)
Unprofessional Conduct of substance abuse professionals as reported in Chapter RL 164 by
the Department of Regulation and licensing is clear. Specifically (i) altering or falsifying patient
records, (k) revealing info without a release of information, (r) failing to provide patient with
reasonable descriptions of tests; consultations; reports, fees, billing, therapeutic schedule or
regimen;(s) failure to conduct assessments’, evaluation or diagnosis as a basis for treatment
provided and (t) failure to maintain adequate records relating to services provided a client in
the course of the professional relationship. Any of these failures to comply can constitute
reason for the state to remove a substance abuse counselor’s license or issue a fine. The laws
and codes of ethics need to be followed exactly to protect the client and the client’s rights.
Counselors who fail to do this are not living up to their responsibilities as a helping professional.
I hope all counselors will live up to their responsibilities so our clients will not have to worry
about those that do not protect client rights.
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WORKS CITED
HFS 75.03. (2011, August 31). Retrieved September 25, 2011, from
http://docs.legis.wisonsin.gov/statutes/statutes/51.pdf
Office for Civil Rights. (2011). Retrieved October 11, 2011, from HIPPA:
http://www.hhs.gov./ocr/privacy
Gerald Corey, M. S. (2011). Issues and Ethics in the Helping Professional. Belmont, CA, USA:
Brookes/Coles.
National Center for Biotechnology Information,. (n.d.). Retrieved march 12, 2013, from
http://www.ncbi.nlm.nih.gov: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC162256/
Services, I. D. (n.d.). Retrieved March 12, 2013, from
http://www.dhs.state.il.us/page.aspx?item=40657
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