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 of the dates of counseling, social work, or marriage and family therapy services, types of counseling, social work, or marriage and family therapy services, 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) Counselors, social workers, and marriage and family therapists 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 written. Clinical records shall include but not be limited to appropriate diagnosis, if any; individual service plans; in-take assessments; informed consent documents; and releases of information documents.

(C) Counselors, social workers, and marriage and family therapists 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) Counselors', social workers', and marriage and family therapists' 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) Counselors, social workers, and marriage and family therapists 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) Counselors, social workers, and marriage and family therapists shall provide clients with reasonable access to records concerning the client. Counselors, social workers, and marriage and family therapists who are concerned that clients' 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. Licensees should limit clients' access to their records, or portions of their records, only in exceptional circumstances when there is compelling evidence that such access would cause serious harm to the client. Both the clients' requests and the rationale for withholding some or all of the records shall be documented in the clients' files. When providing clients with access to their records, licensees shall take steps to protect the confidentiality of other individuals identified or discussed in such records.

(G) A counselor, social worker, or marriage and family therapist shall not condone, partake, or assist in billing irregularities or fraud with respect to insurance companies or direct billing.

(H) Counselors, social workers and marriage and family therapists 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 counselors, social workers, or marriage and family therapists leave a practice, they shall follow a prepared plan for transfer of clients and files. Counselors, social workers, or marriage and family therapists 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. Each licensee responsible for client files outside of an agency shall report to the board on the biennial registration (renewal) form the name, address, and telephone number of a licensee or other appropriate person knowledgeable about transfer and custody of records and responsibility for records in the event of the licensee's absence, incapacitation or death. Licensees at agencies that close can reference division (A)(14) of section 5122.31 of the Revised Code for proper transfer of records.

R.C. 119.032 review dates: 10/12/2012 and 09/20/2017
Promulgated Under: 119.03
Statutory Authority: 4757.11
Rule Amplifies: 4757.11
Prior Effective Dates: 9/19/85 (Emer.), 12/19/85, 5/22/86, 6/11/95 (Emer.), 7/3/97, 8/2/01, 9/20/02, 4/10/04, 1/1/06, 11-8-07, 11-2-08, 10-18-09, 4-1-11