Rule 4757-5-09 | Standards of ethical practice and professional conduct: record keeping.
(A) Record keeping requirements: For each client/consumer of services, a licensee or registrant shall keep records and case notes of the dates of counseling, social work, marriage and family therapy services, art therapy, and music therapy services; types of counseling, social work, marriage and family therapy, art therapy, or music therapy services; a brief summary of the session; termination, and billing information. Records held by the licensee shall be kept for seven years. Records held or owned by government agencies or educational institutions are not subject to this requirement. Licensees shall keep all records in a secure location and shall allow only authorized persons access to records.
(B) Licensees and registrants shall take reasonable steps to ensure that documentation in records is accurate and reflects the services provided. Dates reflected in case notes shall be accurate with respect to dates of service and dates the case notes were recorded. Clinical records shall include but not be limited to appropriate diagnosis, if any; treatment plan, revisions to the treatment plan, correspondence , individual service plans, in-take assessments, informed consent documents, and releases of information documents. All notes regarding a client(s) must be developed and approved by the licensee or registrant and shall not be the sole work product of any other person or software/information technology system.
(C) Licensees and registrants shall include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future.
(D) Licensee or registrant documentation shall protect clients' privacy to the extent that it is possible and appropriate and shall include only information that is directly relevant to the delivery of services.
(E) Licensees and registrants shall store records following termination of services to ensure reasonable future access. Records should be maintained as required by this rule unless a longer retention period is required by statute or relevant contracts
(F) Requirements regarding client access to records are established in section 3701.74 of the Revised Code. Licensees and registrants shall provide clients with reasonable access to records concerning the client. Licensees and registrants who are concerned that a client's access to their records could cause serious misunderstanding or harm to the client shall provide assistance in interpreting the records and consultation with the client regarding the records. If a licensee or registrant who has treated the client determines for clearly stated treatment reasons that disclosure of the requested record is likely to have an adverse effect on the client, the licensee shall provide the record to a physician, psychologist, licensed professional clinical counselor, licensed professional counselor, independent social worker, social worker, independent marriage and family therapist, marriage and family therapist, or chiropractor designated by the client. The licensee shall take reasonable steps to establish the identity of the person making the request to examine or obtain a copy of the client's record.
(G) A licensee or registrant shall not condone, partake, or assist in billing irregularities with respect to insurance companies or direct billing.
(H) Licensees and registrants shall be aware of and adhere to divisions (H)(1) and (H)(2) of section 3109.051 of the Revised Code. That section in part states: "a parent of a child who is not the residential parent of the child is entitled to access, under the same terms and conditions under which access is provided to the residential parent, to any record that is related to the child and to which the residential parent of the child legally is provided access...unless the court determines that it would not be in the best interest of the child for the parent who is not the residential parent to have access to the records under those same terms and conditions...any keeper of a record who knowingly fails to comply with the order or division (H) of this section is in contempt of court." A complete reading and understanding of this section is mandatory for any counselor, social worker or marriage and family therapist providing services for children.
(I) When licensees and registrants leave a practice, they shall follow a prepared plan for transfer of clients and files. Licensees and registrants, with the exception of registered social work assistants and registered trainees, shall prepare and disseminate to an identified colleague or "records custodian" a plan for the transfer of clients and files in the case of their incapacitation, death, or termination of practice. Licensees at agencies that close can reference division (A)(14) of section 5122.31 of the Revised Code for proper transfer of records.
Last updated March 19, 2024 at 12:15 PM
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