Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
APPENDIX: SUMMARIES OF ETHICS CODES Relevant information regarding record keeping American Association for Marriage and Family Therapy Ethics Code (2015) http://www.aamft.org/imis15/content/legal_ethics/code_ of_ethics.aspx Standard II: Confidentiality 2.5 MFTs [marriage and family therapists] comply with applicable laws and professional standards with respect to storing, safeguarding, and disposing of records such that clients’ confidentiality is protected. 2.6 MFTs arrange for the confidentiality, storage, transfer, safeguard, or disposal of client records in the event of the therapist’s move from the area, practice closure, or death in conformance with applicable laws. Standard III: Professional Competence and Integrity 3.5 MFTs maintain clinical and financial records in accordance with applicable law. Standard VI: Technology-Assisted Professional Services 6.2 MFTs make clients aware of the risks and responsibilities associated with the use of technology-assisted services in writing. 6.3 MFTs make clients aware of limitations and protections offered by the therapist’s technology in writing. 6.4 MFTs ensure that documentation that is stored or transferred electronically adheres to best practices with respect to maintaining confidentiality and quality services. MFTs are to notify clients in writing of the technology’s limitations and protections. Standard VIII: Financial Arrangements 8.6 MFTs may not withhold records because of non-payment for services, except as otherwise provided by law. American Counseling Association Code of Ethics and Standards of Practice (2014) http://www.counseling.org/Resources/aca-code-of-ethics.pdf
A.2.b. Types of Information Needed All services provided by the counselor are explicitly explained to clients. Clients are informed by counselors about the coun- selor’s credentials and experience in service provision and the service’s purposes, goals, techniques, procedures, limitations, potential risks, and benefits. Counselors explain about their management plan for a client’s services upon the incapacita- tion or death of a counselor. Counselors ensure that clients have clear information about their records and understand the implications of diagnosis, tests and reports, fees, and billing arrangements. Clients have the right to confidentiality and to be informed of all the limita- tions to the counselor’s maintenance of their confidentiality. Clients have the right to refuse any services and to be advised about the consequences of such action.
Section B: Confidentiality and Privacy B.6. Records and Documentation
B.6.b. Confidentiality of Records and Documentation Counselors ensure that client records and documentation are secure and can be accessed only by authorized persons. B.6.c. Permission to Record Counselors must seek and be granted permission to record a client’s session through electronic or other methods. B.6.e. Client Access Counselors provide reasonable access to records and copies of records when requested by competent clients. Such access is limited only when compelling information suggests that access would harm the client. All client requests for access are documented by counselors. Withholding any portion of the record is documented with accompanying rationale. In instances involving multiple clients, -counselors do not release confidential information about any other clients to the requesting client. B.6.g. Disclosure or Transfer Counselors disclose and transfer records to legitimate third parties only when they have obtained written permission from clients for the disclosure, unless exceptions to maintaining confidentiality are present. American Psychological Association Ethical Principles of Psychologists and Code of Conduct (2017) http://www.apa.org/ethics/code/ 6. Record Keeping and Fees 6.01 Documentation of Professional and Scientific Work and Maintenance of Records Psychologists create, disseminate, store, retain, and dispose of records related to their professional work that facilitates the provision of services, complies with legal and institu- tional requirements, and ensures accuracy.
Section A: The Counseling Relationship A.2.a. Informed Consent
Clients choose whether or not to enter into or remain in a counseling relationship. Clients should be provided with information verbally and in writing about the counselor and what to expect from the counseling process. Counselors review in writing and verbally with clients the clients’ and counselors’ rights and responsibilities. Informed consent is revisited and documented throughout the counseling process.
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