counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.” Release of this information requires a HIPAA compliant release form signed by the client with a few exceptions: 1. To carry out the following treatment, payment, or health care operations: a. Use by the originator of the psychotherapy notes for treatment; b. Use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or c. Use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and 2. A use or disclosure that is required by another law, such as reporting abuse or disclosures to avoid harm to patient or others.
The mention of “another law” exception covers the mandatory duty to report child abuse in all 50 states and the laws governing duty to warn. Counselors should be aware that 2013 brought important changes to HIPAA and that September 23, 2013, was the compliance deadline for many of these regulatory requirements. Any counselor or therapist who is not sure if they are considered a “covered entity” under HIPAA should immediately access the online decision-making tool available at the website of the Centers for Medicare and Medicaid Services. All counselors who are covered entities should move quickly to come into compliance or risk very stiff monetary penalties (ACA, 2014). With more than 800 pages, the entire HIPAA document and Privacy Rule is extensive. Covered entities regulated by the rule are obligated to comply with all of its requirements and should not rely on this summary as the source of legal information or advice. Professionals should receive specialized training and continuing education on HIPAA regulations related to their practice. To view the entire rule, and for other information about how it applies, review the website at http://www.hhs.gov/ocr/privacy/. Counselor educator: A professional counselor engaged in developing, implementing, supervising, monitoring, and evaluating the educational preparation of professional counselors. Counselor services agreement: Written document that informs the client of the terms and conditions of the counseling or therapeutic service. It includes potential benefits and risks. Counselor supervisor: A licensed, practicing counselor in a formal professional relationship with a student counselor or a counselor-in-training to oversee the individual’s counseling work or clinical skill development. Culture: The customary beliefs, social norms, institutions, behavior patterns, values, and lifestyles of a particular community or group. Deceptive methods: Any methods used in which clients are unaware, misinformed, or denied informed consent. Digital technology: Digitized information recorded in a binary code of combinations of the digits 0 and 1, called bits, which represent words and images. Digital technology enables immense amounts of information to be compressed on small storage devices that can be easily preserved and transported including the Internet, digital mobile devices, and systems used in communication and social media. Discrimination : To make distinctions or to differentiate based on preference or prejudicial views of an individual or group. Distance counseling: The therapeutic or counseling services delivered without physical proximity to the client by using technology as the point of access. Diversity: The differences and distinct qualities within cultures and social groups. Documents : Written, digital, or audio/ visual records of client information within the counseling or therapeutic relationship with clients. Encryption : Process of encoding information to protect identity and to block access by unauthorized parties. Examinee : The client who is being assessed for the purpose of determining psychological, educational,
GLOSSARY
Professional counseling and marriage and family therapist associations, such as the NBCC, ACA, and AAMFT, have terms and definitions in common that are seen throughout their ethical codes. Some of the most commonly used terms and their definitions are as follows: Abandonment : The ending or termination of a counseling or therapeutic relationship that harms a client or puts the client at risk. Advocacy : Actions to promote the welfare of individuals and groups to remove barriers and increase access to reach their full potential. Advocacy includes supporting policy changes to promote these goals for all individuals. Assent : Actions that indicate or demonstrate agreement when a person is not capable or competent to give informed consent. Bartering : Goods or services that are accepted from clients in exchange for counseling or therapy services. Client : Individuals or groups at the point where they make contact and ask for services. Client record: The paper or electronic system containing all information gathered and stored throughout service delivery. This may include written, electronic audio, and video records. Clinical supervision: Guidance, mentoring, education, coaching, and monitoring by a practicing professional to enable the development of professional skills and facilitate learning in application of skills to practice settings. Competency : Therapists and counselors provide services only within the boundaries of their expertise based on education, training, license, certification, and experience. Confidentiality: The ethical duty of counselors to protect client identity, communications, or any information related to the relationship with clients. Consultation: A professional collaboration that includes advice, information, assistance, support, or testimony. The codes promote professional consultation. Counseling: A professional relationship that aids diverse individuals, families, and groups of all ages to enhance mental health, wellness, education, and career goals.
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Book Code: PCUS1525
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