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