Flashcards in Therapy records / Professional Will Deck (24):
Maintaining therapy records is ?? matter.
legal and ethical
I need to keep therapy records for ? years for adults.
I need to keep therapy records until ? for children.
age 25 (7 years after turning 18)
Therapy records must be stored in?
locked, inaccessible to others location
What information need to be in therapy records?
1. chief complaint
2. any findings from consulting other professionals
3. signed consent
4. treatment plans and progress notes
6. Insurance information
7. Emergency contact
8 Any crisis related records
Therapy records are owned by?
therapist or her/his agency
In order to request records, patient must?
make a written request
Therapist has ? days to allow patient to inspect/read records.
5 business days
Therapist has ? days to give patient a treatment summary.
10 business days
Therapist must provide a copy of records in ? days.
15 business days
When can a therapist refuse to release patient records to the patient?
There is a high possibility for detrimental consequences.
When refusing to release patient records to the patient, therapist must do ??
1. note the date of the request.
2. document a specific detrimental consequences foreseen.
3. Inform the client that I received the request and that denying the request.
4. Inform the client his/her right to have another licensed professional to inspect/receive records.
When a patient found an error in his/her record, he/she has a right to request ?
addendum to correct the record for up to 250 words.
When can I refuse to release minor's records to parents?
If I believe releasing records would harm the minor or our therapeutic relationship (only for kids under 12).
If a client is old enough to consent (12 or older), what needs to be done when parents/others request records?
The minor patient (12 or older) must sign consent.
I must have a ? to share patient information with others.
a written release (not verbal)
The font on release form must be ?
14 or larger
If you don't have a printed ROI on hand, what should I do?
Patient must handwrite the form her/himself on a piece of paper.
ROI must specify ? (2)
1. what information to be disclosed
2. the name and function of person receiving info.
ROI must have ? date and patient's right to?
a copy of the authorization/ROI
When I receive ROI from other professionals, I don't need ?
my own ROI signed by patient.
What is Professional Will?
A document that outlines what need to be done if I die or become incapacitated unexpectedly.
Professional Will designates ?
a licensed professional that will oversees patient referrals.