Recordkeeing

Requirements

for the

Counseling

Professional The Musts, The Shoulds,

and The Definitely Nots!

Laura Diamond

Carls, McDonald & Dalrymple, LLP

(512) 422-8810

ldiamond@cmcdlaw.com

www.cmcdlaw.com

CAVEAT:These materials have been prepared for the information

and general use by attendees of this course. To the best

of my knowledge, the information contained in this

presentation is accurate. I am reasonably sure that my

citations are correct. However, neither the text of this

presentation, nor any remarks made during the lecture

are intended for use as legal advice. Please consult an

attorney who specializes in these areas for legal advice

on all real or potential problems. Further, the opinions

expressed in this paper and during the lecture are my

own, and are not necessarily the opinions of the Texas

Counseling Association.

Where do we find the rules?

LPC

www.dshs.state.tx.us/counselor/

LMFT

www.dshs.state.tx.us/mft/

LCSW

http://www.dshs.state.tx.us/socialwork/

LCDC

http://www.dshs.state.tx.us/lcdc/

Additional useful information

on the Boards' websites

Renewal Applications

Forms

Links to Texas and National Associations

Enforcement Actions

Contact Information for the Board

THE MUSTS

What records do

the rules require?

MUST: LPC Rule 681.41(q)

For each client, licensee shall keep

accurate records of

Intake assessment

Dates of treatment

Principal treatment methods

Progress notes

Treatment plan

Billing information

LPC Rule 681.41(t)(6)

Prior to the commencement of

counseling services to a minor client

who is named in a custody agreementor court order, a licensee shall obtain

and review a current copy of the

custody agreement or court order, as

well as any applicable part of the

divorce decree. A licensee shall

maintain these documents in the

client's record.

MUST: LMFT Rule 801.48(e)

A licensee shall keep accurate records

of therapeutic services to include, but

not be limited to

dates of services

types of services

progress or case notes

billing information

MUST: LCSW Rule 781.209

The licensee shall…keep accurate and

legible records of the

dates of services

types of services

progress or case notes

intake assessment

treatment plan

billing information*

MUST:

LCDC Rule 140.423(f)(2)

Applies to all LCDCs

A Licensee shall maintain complete,

accurate, and appropriate

documentation of services provided

MUST:

LCDC Rule 140.424(a)(1)

In addition, LCDCs in private practice

The client record shall include:

client identifying information

assessment results, including a statement of the client's problems and/or diagnosis

plan of care

MUST:

LCDC Rule 140.424(a)(1), con’t

The client record shall include:

documentation of all services provided,

including date, duration, and method

of delivery

a description of the client's status at the

time services are discontinued

MUST: LCDC Rule140.424

(2) The counselor shall maintain a record of all charges billed and all payments received.

(3) All entries shall be permanent, legible, accurate, and completed in a timely manner.

(4) All documents and entries shall be dated and authenticated. Authentication of electronic records shall be by a digital authentication key.

(5) When it is necessary to correct a record, the error shall be marked through with a single line, dated, and initialed by the counselor.

MUST: Client Record Retention

LPC Rule 681.41(r)

Minimum of 5 years from date of last contactwith client

LMFT Rule 801.48(e), LCSW Rule 781.209(4), andLCDC Rule 140.424(a)(9)

Minimum of 5 years for an adult client and 5years beyond the age of 18 for a minor

* Per, Texas HIPAA, must keep records for 6 years!

MUST: Supervision Records

LPC Rule 681.93(d)

A board approved supervisor shall maintain andsign a record(s) to document the date of each

supervision conference and document the LPC

Intern's total number of hours of supervised

experience accumulated up to the date of the

conference. The record shall reflect the approved

site where the hours were accrued and the

content of the supervision.

MUST: Supervision Records

LMFT Rule 801.143(e)

A board-approved supervisor shall maintain andsign a record(s) to document the date of each

supervision conference and document the LMFT

Associate's total number of hours of supervised

experience accumulated up to the date of the

conference.

SHOULD: Supervision Records

Supervision file should also contain copies of:

Supervisory Agreement Forms

Intern’s license

Intern’s resume

“Employment” documents – job posting/description, application, background and reference checks, confidentiality agreement, payroll records

THE SHOULDS

What records should be

kept?

And how should we keep

the required records?

SHOULD: Progress Notes

But, what should a progress

note include?

SHOULD: Treatment Plan

But, what should a treatment

plan contain?

Templates

The Pros:

A good tool

Can help document required elements

Can be customized to your practice

The Cons:

Use as a guide … the minimum … can always

document more

Blank or incomplete sections

SHOULD

Maintain documentation of compliance with pre-service informational requirements

Anything you are required to informyour client about in writing beforeproviding services.

For example:

Prior to services … inform … in writing:

LPC Rule 681.41(e)(8) and LCSW Rule781.209(4)

Plan for the custody and control of theclient’s records should licensee die, becomeincapacitated, or cease offering services

For example:

Prior to services … inform … in writing:

LPC Rule 681.41(e)(4) limits onconfidentiality

LCDC Rule 140.423(l) rights regardingconfidentiality

Another example:

Prior to services … inform … in writing:

LPC Rule 681.41(e)(1) fees and

arrangements for payment

LCDC Rule 140.423(l) fee schedule and

establish financial arrangements with a

client.

SHOULD: Billing Records

LPC Rule 681.41 General Ethical Requirements

(f) bill clients … for only … services actually

rendered

LCDC Rule 140.423 Professional and Ethical

Standards

(l) …counselor shall not charge exorbitant or

unreasonable fees

SHOULD

Maintain documentation of required reporting

Abuse or neglect of minors

Abuse, neglect & exploitation of elderly

Abuse, neglect, illegal, unprofessional or unethical

conduct by treatment facility

Sexual exploitation by another mental health provider

THE DEFINITELY NOTS!

What your records should

never contain.

How not to handle records.

Text Messages

• Use sparingly, if ever, and only for scheduling!

• Are part of the

client’s chart –

do you know

how to print a

text message?

Emails

Not recommended!

Use only for scheduling

Part of the client’s record

What if the client emails personal

information?

Responding to

Requests for Records

From the Board

MUST: Respond to Board’s request – provide everything!

Cooperate with investigation

SHOULD: Provide organized, page numbered chart

Provide color copies, if necessary

Type notes, if necessary

DEFINITELY NOT: Ignore the request

Remove or alter documents

From a Client MUST:

Must provide copy (H&SC Ch. 611.0045)

May charge for the copy

SHOULD:

Keep a record of the request and what was

provided

DEFINITELY NOT:

Ignore the request

Consequences:

Disciplinary Actions

Related to Recordkeeping

Administrative Penalty

LPC failure to provide/complete required supervisory agreement

form; failure to keep supervision records ($500)

LPC failure to respond to the Board regarding a complaint

($1,000)

LPC failure to release client records to client’s father ($2,000)

LMFT failure to comply with H&SC Ch. 611 regarding release of

records ($250)

Reprimand LPC failure to retain records and inability to comply with

H&SC 611 (+ $500 administrative penalty)

LPC dual relationship and releasing client’s records without

consent

LCSW failure to keep adequate records and records

contained billing inaccuracies

LPC failure to keep accurate records

Probated Suspension

LPC failure to maintain professional boundaries, dual

relationship with a client and failure to keep accurate

client records (1 yr)

LPC failure to set/maintain professional boundaries, dual

relationship with client, failure to respond to Department

Investigator, and failure to provide documents at Board’s

request (2 yrs)

LCSW failure to keep adequate patient records (1 yr)

Revocation

LMFT failure to set and maintain professional

boundaries by entering into a dual

relationship with a client, failure to take

reasonable precautions to protect minor

client from physical and emotional trauma,

failure to offer services within professional

competency, failure to keep accurate client

records and failure to timely respond in writing

to a Board request regarding client records.

Recordkeeping Matters!

The Rules tell you what Must be recorded

Common sense and experience tell you

what Should (and Definitely Not!) be

recorded

Sources for support

Board website

Colleagues

Legal Counsel

Laura Diamond

Carls, McDonald & Dalrymple, LLP

(512) 472-4845

www.cmcdlaw.com