Post on 16-Apr-2017
Standards on Record Keeping and Fees
Standards on Record Keeping and FeesKayla S. BordelonPSYC 3800
6.01 Documentation of Professional and Scientific Work and Maintenance of Records
6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work
6.03 Withholding Records for Nonpayment
Overview
6.01 Documentation of Professional and Scientific Work and Maintenance of Records
Multiple Client Records
When providing for couples or families, professionals must keep private all records. Access to files include:
A) family unit or each individual
B) legal requirements
C) Agreement on the record keeping policyRECORDS FOR MENTAL HEALTH SERVICES
Along with state, federal, and certain institution requirements, records are to be maintained for a minimum time..7 years after the last date of service for an adult or until 3 years after minor reaches age of majority.Length of Record Retetion
Personal notes
Exempt from subpeonas
Can be disposed of at any time HIPPA creates a category for personal notes.
Personal notes are exempt from HIPPA billing, payments, or other operations.
Psychotherapy Notes
Records should include documentation of billing agreement.
Barter agreements and transactions
Document and justify any adjustment in balance owed
Fee collections recorded
Billing and Fees
Organizations have their own record keeping requirements
Record organization is set by relationship with the organization and the professional
Multiple staff members have access and contribute
RECORD KEEPING IN ORGANIZATIONAL SETTINGS
Forensic records must be created and maintained to be used appropriately in legal matters
All records used for a case is subject for discovery
Forensic Records
Records must be maintained in order for replication
Federal regulations state records should be maintained for 3 years
Federally funded grants must maintain a record of participant compensation, assistant salaries, equipment, travel, balances, and time and effort reporting
DOCUMENTATION OF SCIENTIFIC WORK AND MAINTENANCE OF RECORDS
6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work
Required when information is transmitted in electronic form for
Health care claims, health plan premium payments, referral certification, injury reports, and transfer of records to other professionals
Professionals must keep doors locked and must store information to where guests are unlikely to see
Terminated employees do not have access to any informationProtected passwords, de-identify information
Implications of HIPAA
Physical records may belong to organization and can not leave premise.
Advanced planning is needed for secure transfer of such records in case of planned or unplanned events
Psychologist transferring forensically relevant records should be familiar with any laws
Psychologist Working With or in Organizations
6.03 Withholding Records for Nonpayment
Under the Ethics Code, psychologist are not required to obtain the clients consent to release information due to an emergency
HIPAA permits disclosure also without having informed consent by patient
Emergency Treatment
All records must be under the psychologists control
The records must also be requested
Control and Request
HIPAA Privacy Rule does not distinguish between emergency and nonemergency requests
HMO contracts with psychologists
Regulatory and Legal Caveats
Fisher, C. (2013). Decoding the ethics code: A practical guide for psychologist. (3 ed., pp. 178-190). Los Angelos: SAGE.References