Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
portions of their records, only in exceptional circumstances when there is compelling evidence that such access would cause serious harm to the client. Both clients’ requests and the rationale for withholding some or all of the record should be documented in clients’ files. (b) Social workers should develop and inform clients about their policies, consistent with prevailing social work ethical standards, on the use of technology to provide clients with access to their records. (c) When providing clients with access to their records, social workers should take steps to protect the confidentiality of other individuals identified or discussed in such records. 1.12 Derogatory Language Social workers should not use derogatory language in their writ- ten, verbal, or electronic communications to or about clients. Social workers should use accurate and respectful language in all communications to and about clients. 3.04 Client Records (a) Social workers should take reasonable steps to ensure that documentation in electronic and paper records is accurate and reflects the services provided. (b) Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future. (c) Social workers’ documentation should protect
Directive 10: NCCs are to create formal, written procedures for the handling of client records in the case of death or incapacitation. Directive 16: All test results and assessments can only be released to others with written client consent unless in the case of imminent danger or when legally required to. Directive 19: NCCs must create written practice procedures in regard to social media and digital technology and are to be provided to clients before or at the time of the first session. these shall be incorporated with the information provided to clients before or during the initial session. Policies are to include guidelines for use of social media including personal versus professional accounts (such as “friending”). Directive 43: NCCs are to ensure the accuracy of all writ- ten reports based on shall provide direct experiences with individual(s) or documentation from other professionals. Directive 54: All written communications, including those through digital technology must be made part of the client’s official record, including those of a clerical nature. Password security and encryption are to be used for all electronic thera- peutic communications. Directive 55: Client records must be kept for at least five years unless state or federal law states differently. Directive 72: NCCs shall obtain a client’s consent prior to the provision of services. In private practice or other similar situations, this consent shall be documented in writing in a counseling services agreement. This counseling services agree- ment shall become a part of the client’s record. Directive 74: Client records are to be updated throughout the counseling relationship when changes occur in the treatment plan, including those relating to goals, roles and techniques. Directive 75: The primary client must be clearly identified in the client record, as well as others receiving related professional services in connection with the primary client.
clients’ privacy to the extent that is possible and appropriate and should include only information that is directly relevant to the delivery of services.
(d) Social workers should store records following the termination of services to ensure reasonable future access. Records should be maintained for the number of years required by relevant laws, agency policies, and contracts. National Board for Certified Counselors (2016) http://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf Directive 1: NCCs [nationally certified counselors] will not share information that is obtained through the counseling process without specific written consent except to prevent clear, imminent danger to the client or others or when required to do so by a court order.
WORKS CITED https://qr2.mobi/EthicsInBH
29
EliteLearning.com/Psychology
Powered by FlippingBook