Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
Section B: Confidentiality and Privacy B.6. Records and Documentation
(c) Psychologists make advance plans for confidential record maintenance in the event of their withdrawal from positions or practice. (See also Standards 3.12, Interruption of Psychological Services, and 10.09, Interruption of Therapy.) 6.03 Withholding Records for Nonpayment Psychologists may not withhold records needed for a client’s emergency treatment because of nonpayment. National Association of Social Workers Code of Ethics (revised 2017) https://www.socialworkers.org/About/Ethics/Code-of- Ethics/Code-of-Ethics-English 1.07 Privacy and Confidentiality (j) Social workers should protect the confidentiality of clients during legal proceedings to the extent permitted by law. When a court of law or other legally authorized body orders social workers to disclose confidential or privileged information without a client’s consent and such disclosure could cause harm to the client, social workers should request that the court withdraw the order or limit the order as narrowly as possible or maintain the records under seal, unavailable for public inspection. (k) Social workers should protect the confidentiality of clients when responding to requests from members of the media. (l) Social workers should protect the confidentiality of clients’ written and electronic records and other sensitive information. Social workers should take reasonable steps to ensure that clients’ records are stored in a secure location and that clients’ records are not available to others who are not authorized to have access. (m) Social workers should take reasonable steps to protect the confidentiality of electronic communications, including information provided to clients or third parties. Social workers should use applicable safeguards (such as encryption, firewalls, and passwords) when using electronic communications such as e-mail, online posts, online chat sessions, mobile communication, and text messages. (n) Social workers should develop and disclose policies and procedures for notifying clients of any breach of confidential information in a timely manner.
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. 6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work (a) Psychologists ensure confidentiality in creating, storing, accessing, transferring, and disposing of records under their control regardless of medium. (See also Standards 4.01, Maintaining Confidentiality, and 6.01, Documentation of Professional and Scientific Work and Maintenance of Records.) (b) Psychologists must use coding or other confidentiality-maintaining techniques so that participants may not be identified by others who have access to the record but do not have permission to access the participant’s confidential information.
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