Professional Ethics and Law in California, 2nd Edition _ ____________________________________________
• Documentation reflects only information relevant to service delivery. • Client privacy is maintained to the extent possible and appropriate. • Records are stored for a sufficient period after termination. RECORD KEEPING State statutes, contracts with state agencies, accreditation bodies, and other relevant stakeholders prescribe the mini- mum number of years records should be kept. For example, HIPAA has a requirement of 6 years for electronic records. The Council on Accreditation and the State of California (Business and Professional Code, Chapter 14, Section 4993) requires records be kept a minimum of 7 years. The NASW Insurance Trust actually strongly recommends retaining clini- cal records indefinitely. In the state of California, “if the client or patient is a minor, the client’s or patient’s health service records shall be retained for a minimum of seven years from the date the cli- ent or patient reaches 18 years of age” (California Legislative Information, 2020a). Again, professionals who are primary custodians of client records should refer to additional legal requirements, such as those established by state licensing boards, regarding care for client records in the event they retire and/or close their business or practice.
ETHICS IN PRACTICE SETTINGS
ADMINISTRATION Mental health administrators should advocate within and outside their agencies for adequate resources, open and fair allocation procedures, and a work environment that is not only consistent with but encourages compliance with ethical standards of practice. Ethical standards of practice should be included with materials given to new workers and emphasized during staff hiring. And some form of ethics language should be included with a mission statement. BILLING Practitioners need to establish and maintain accurate bill- ing practices that clearly identify the provider of services. Many agencies, associations, and boards include these expectations in their own values and codes of ethics, commonly under the category of stewardship. CLIENT TRANSFER Mental health practitioners should consider the needs and best interests of clients being served by other professionals or agencies before agreeing to provide services, and discuss with the client the appropriateness of consulting with the previous service provider. Informed consent is an important aspect of this issue, in that a practitioner must discuss all implications, including possible benefits and risks, of entering into a rela- tionship with a new provider. CLIENT RECORDS Maintaining records of service and storing them is not always easy. Aside from the potential negative legal fallout of not doing so, there are good reasons for keeping records including: • Assisting both the practitioner and client in monitoring service progress and effectiveness . • Ensuring continuity of care should the client transfer to another worker or service . • Assisting clients in qualifying for benefits and other services . • Ensuring continuity of care should the client return . To facilitate the delivery and continuity of services, the practitioner, with respect to documentation and client records, must ensure that: • Records are accurate and reflect the services provided. • Documentation is sufficient and completed in a timely manner.
THE ETHICAL IMPORTANCE OF DOCUMENTATION
Documenting according to ethical standards is relevant to all clinicians. With technological advances, digital documenta- tion has become increasingly the norm; however, electronic health records and other forms of electronic communication pose their own ethical risks in documenting services. For social workers, counselors, marriage and family thera- pists, and psychologists, documentation is equally important before, during, and after a clinical encounter. A common adage states: “If it isn’t written, it didn’t happen.” Although documentation serves multiple essential purposes, it is fraught with risk and liability. Practitioners usually know what is minimally required in documentation; however, what is least required may differ significantly from what is recommended or optimal. Optimal documentation includes information that is relevant to the clinical services being provided and that addresses legal, ethi- cal, and administrative obligations. Agency practice and time demands often result in practitioners documenting only what is required. This practice may leave the agency and practitioner open to scrutiny and risk and, at the same time, shortchange the client’s services.
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