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 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 recorded. 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) Requirements regarding client access to records are established in section 3701.74 of the Revised Code. 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 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 counselor, social worker, or marriage and family therapist 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 counselor, social worker, or marriage and family therapist shall not condone, partake, or assist in billing irregularities 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. Licensees at agencies that close can reference division (A)(14) of section 5122.31 of the Revised Code for proper transfer of records.