Msft6008 Reading12

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lli.hrj.,

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his r f iic le .x p l o rc s a v r ri c r l of l. s a l rn d e rh i c .l i$ues r c l a rc d to k e c p i D g, c lir ic nl . e c o rd s .I c .l u ri o rl r har any o r a l l o frh e i s s u e s di\cLrsred.nd rbc ofi joDscxprc$ed in rl ri si ]r r ic lcm iy bec o! e fe (l a Ds.lo v e rn e d h y r p . r f t ic uhf s r r r e l .rw o r rc g u l a ri o n rpplic.rblc to N,IF'l!. I s,ill renri.d rhc ' rcederof rhat frct severaltimcsrhroLrgho rrrrhc r r r ic le, bur niy l a i l rre ro d o s o $ o u l d lor ler d r hc r . .d e r ro c o n c l rd c : rhr! n., bxrdng sr.rc law or reguhtio! r e y,!!s Thc . wor ds" c lic n r"x n d " p n r;e n i ' ' .ft use,l inrerchrngeiblv in rhis article. ' P.rt II .,f ihis arricle will apl)e.]r in e d e \r oJ r his m .s a z n re rn d w i l l '$ uc rdd.ess $rdr issuesas lost, desroycd !nd srolrn rccords,acccssro recofdsbv t)ricnrs rDd trrents, and dispositionof . recoels upon rhe dcath of a therapjst. :

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Wh y K € e p R ecords? Aside fron thc frct lhrr ir m.1y bc .equired, it is sood bLrsintssfr.rftice ro keet rccords of thc uans.ciidrs rDd o c c n rre n c es w i thi n any busi noss. \V i rh rcspcct to herlth crrc froiessnDs, rhe nced for sood recorcl keeping is rnore lmporrart! sincethe Dcrrrl or physical h c a l rh o frpati enti si l vol ved,asaresi gnificint mrrital, fanily, and orher inrefpersonrl rehrnnships. SoDretherapisrs h e v e o p i n ed rhat they kecp mi ni mal records in order ro prorect thc privacy of rhe p,tienr. I scnenlly disagrcewith rh.r approach to record keepins. The laws oI confidentiaiity end psychorher apisr-patientprivilcse(rnd horcrc.enr lx HIIAA)protcci privacy,.s do rhetri v!cy trrctices of the rherNpist. (;ood record keeping ls npoftrnr borh to clientsand ro rheripisrs. Clienrs

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j_ir., ,{r:,,!tr} ar}r',!11f,!-.1 lnr) Dccd ro prove rheir m.nrrl status .rr thar lhey sufferedemorionrl distrcss or othcr i nrpri netrr.' l h( ncedt o do so may artre In n custodyorvisirxrion proceednig,in .r civil lawsuir for damagcs, in ordcr to qu.lify for reinburremenr, w orkeri compensrri onor disabili' n. ty case,for a securirycleriance, or for someorherrcason.C l i enrsdetendupoD thei. rher.rpistsro keep adcquare .tnrl rccnrare records,whi.h can help provc, atnongodrerrhi ngs,drerrheya r e beir g t| ei ted l or i pi rti cul rr menrald isor def o. th.t thcy sul d nri rkc. B oodcusk! di al p.renr. A ddi rl oni 1l l xtri i cr r s f i. ve i rlglrt to expcct tbrt ll thry were ro obtri i rrei rmcnr.r. l rrer ti nr e f r , ) nl inother prrctirioncr, rhtri rhc recoftl\ from drc fri or rhcr.fi sr w (rrl d b . r vr t l rbl c to the ncw drcrrpi st,i f ncc t leLl. (nrod recol i keepi rg c.u h elp t hc thcrrpi sr esr.bl i sh rhrt he/s he. r ct e( l i pnropri rrcl y i i suedby rhc fxr ler r lol (! i f rherc i s i di sc ir lir r r ! ncgl i gcnce, trocecd;ngby rhc l i cenri rl gb(,if t lor r n i l ]vesri gl l ri i )n by.rn ethi cs con r nr incc. W hcr i p.ri enrj l rr€nrf r\ orconrnlr ssLr i ci (l e. hf exnmtl c, or causesp hysicr l hanl to others,thc drerrpi sti s nor inf r oqucntl yrhr i arscrof i n i nvestigr r ioD ol hrvsui tto (l ctcrri new hcrheror nor t hc thcrnpist rcicd .rpfrcpriirtely. A mcmbcr of. c.,upl .or frmi l y rccei vingscr v i cesmry try tol rol d rherhcnpi str espoDsi bl efor I di vorceof s.par:rrionor t o. dre l.ss of cusrody or visi$tnln rishrs. V/ell{locDlrerred rccords crn hclp rhe thcrapi srpr' ovcthdt he or she.rcr ed rs a rcaylrablI pmdenr pradirnDer of lil(c licensurewoul.l h:rve.crcd rnder simi-

C onteht of R ecords Some starc laws or reguhrions specify the coDtcrt required to be in rccords m.rinrriDed by Mf-Is and/or othcr licenred hcahh p..,fessionrls, wb,lc othff state laws takc a tlifferenr approachrnd l eaveacru,l conre nr r or he rl i screti onof thc rherrprsr.C ! lif o. ! r ir l.w,lir eramplc, sr.resrhar ir is trnpr{) iessrcDalconducrif !n Ml'Tfails ro keer rccords consistcnt witb sourd clinicrl judsnenr, rhc srandardsof rhe prcfes sion,r.d the Darureofrh. scrvicesbe;ns

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,e n der ed.T his k iil o f s r u r€ p fo y ;d e s ilcxibility for rhe pLactitioner.Marriage rnd frmily therapv.like the practice of n tcd ic ine,r s bot h an a rt a n d a s c i e n c e ,. rn d rheac t ualc ont e n to fa fe c o s h o u l d helcftrorhr soundcliscrctionoftlrc rhef i p i st. O bv nNs ly ,r h(ra p i p r ivirh a sratc hrv or re8ulirion thar ' mrn dt r t r ss pec ilicc o n re n l . ()ne strre law' in speciiytrrg rhe conrcntol r summary of drc 'nrnd:rrory .c.ods, sivespri( rionersuseful,rt:or mrn o n r s io r h( f os s l b l ec o rte ' r!o frh c fu l l rc c or o1.lhc hw s p e c i fi c srh .rrrh c i L rn ]nr ar ynr us t c on ti u t rn to rm i n o n \u (h . s t he c hief c o m p h rrr o r c o n -

inrportant r{) accurately document all biuingsit1d paymerts so.rs ro avoid fee dispureswith pArlents-Thc AAMI,T's Code of Erhics provid€s rhxr MFTS na intain :ccurate a nd edequ.tc clinical and tinnncial fecords. Amons rhe nrost hchful thnrss ih.r c i n b e d ocumenredarc any consuhntions hid with oihcr fractitidrers who hrve corfnneil or expresscdsupport lof rhe rhc.apisfs trcarment aptroich. Bo rh th e i i cr of thc consul tati on,.nd tl e s u b s t anceof i r, can ofren h(tp ro trove thrr the drenpisr w:rs not ncgliopnri on Se n t.l v e n thoushprofessi onal .nd judgnrenr nray (liffcr. dre thcrapisr

prtrcnr w erc hrvrng an extra- nar ir . l affair, for cxample, the patienr and rhe dlerapisr misht be nore conforrxbte if the nane of the prramour ivas ornittcd fron the recofd.The D rmeofs uch per son rs trequendy not relerant ro thc rpproprirre trcrrment of $e patienr. For H ow Long S houtd R ecords B e Mai ntatned? Stirtelxws viry ;n answer ro rhis ques tion. It seemsas though seven to ren yerrs is withn the upper.range of the tnncsspecificd,iftherc istl specification. Srate laws vary with respcc! ro which pracritioners.rreaffectedby such a hw. for exanl e, (rne sutes do not spec;ly rhe lengrh of rime thar recofth n1usr be maintiined by MrTs, but do specify n ti mefor physi ci nnsor for.,her hhf acili ri es." l n C al i fl )rni ;l ,drere i s no hw (hrccdyapplicllb le rc M|:fs, physicinns, LCSIi/s or psychologisrs.Mnny ofrhose liccntirresfolkrw thc rLrlesapplicrbl€ ro l i ccnsedhrnl i h frci l i ri es,w hi c h r equir e dratrccordsbc preservedfori rnnrinrunr ofsevcnyerrsfol l ow i ngcl i sch . r r ge of t he

5ome therapists keep records indefinitelq, aslonqasstoraoe " does notbecome imaiorp'roblem.

Gene-rallq, state laws donritreruire destiuttion ofrecods given after'a

number ofgears. fl .rn i \ , f er t inenihis t o rv ,fi n d n rg sfro n rnd referrals to othcr h e rh h c r r c pr r r v r t c r sd, i a s n o s i s(w h c rc d tr.n nined) , pr ogk ss o f tr.e a tn c rr, . p ()A.o\ r s ( iD. ludings i s n i fi c .n rc o n ri n , , n 1 .s tn) blc Dr sor c oD d l !i o n s ), p c rri n e n r' rcto ft s oi diignos r i c tro c fd u re s .n d i e sl \ rnd r ll di\ c hlr se s u mme ri e sa, n d o b te .r i\ r lur ding!f f om th H Il, \ A ( ! he" P r iv a c yR u l c " ).rl s o p ro !idcs nseful inform.tion rcgarding tLc co n tc r t oi r c c or ds. J h c re g u l a tn ' r d e s.ribe\r eeof dsasinc h n rg i re m s N c h i \ m.d' c r r ion pr es cri p ti o ra n d mo rofl ng! counselrngsessronsrarrand stop ri n cs, r henodaI nies.n d frc q u e n c i eosf tre :mcr r iur nis hed,rc l rs o f c l i n i c a l re\r!. r.d anv sum arv of fte ioltorvi n q i rrns , diagr os is ,f u n c l i o n a ls ta ru s , th e rre r t m enrplan,s vmp ro n s ,p ro s n o !,sj rrd progrcss ro dar.. It is always

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mry havc!cted conrpetentlyand appropfirtely, albeit not perfectly. Anothcr u s e fu l th i ngro documenri s rhefnctthar rhc therapisrhas referrcd dre parienr to . p h y s i c i rDf(,f I rnedi calex.m, or to a psychiatristfor medicarion,or to orher licensed praclitioners for tcsring or orher scrvices. Of coune, Nch documc.trtion only occurs whcn the theratist is firsr rware of rhe needro consutr or to nakc a referral. It s h o ul d al so be nored, and nor v re w e da s inconsi srcnr ro i hc rbove di e cussrD, !b.r some care and dircreridr should bcexercisedwirh respccrrocontent. Not cvery detail or every spoker word needsro be rccorded. Therapisrs mLrstoitcD bal.ncc colrpeting i,neresis when derermining record conrcnt. Somcrimesa ther!pisr may wrntto or!ii r nane from thc record in orderto protecr the parient or a rhird party. lf l

S peci alcarc shoul tl be i uk er wir h respccrto drc rccords of a minor. It is my b€l i efrhrr rhe rccofdsof a m inor shoukl be kepr a! Ierst three or more yerrs aflerrhe minor hasrcachedrhe rge oi 18 years,ard, i n rny cN se Dor , t ess rhrn sevenyears(unlessa longer rnne is spcci fi edi n hw or resul .ti on ) . Som c therapists keep reco.ds indefinitely, as long . s srorige doesror bcmme a naior problen. cenerilly, staic laws do nor require destrDcrionof records after a giver nurber of years.

What,s the Oanger of E arl y D e3tructi on? Therapistsmustbecarefnlnoi to desrroy records too sooo, even in statcswhere there is no law or regulation requiring thatrccords be kepr fora specifiedpcriodof ti me.Thep.ri entc.n$rerndallcse thrt .rly desrrucrion of rhe records causedhnn/her darnage.For insi.nce, Ihe par;ent nislrr he inv(,lved in higation where thc tlerapistt testimony is necessary. !-ailure!o prodDcerecordsin support of rhe rherapisr\ testinony

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e re l l v d os o enhcrkcruse of. concern rbout their privacy ard confiderrialitv. ,\n or li. r dr n8erol e i rl v rl e s L rn c ti o n or becrusedrcyareupserwtrhtbe results r.kr.; r ( i t h. f r t ienas € x fc c ra r;o nrh rt or tlirectior ofthcrapy anclrvant possi l , r.' lr c r lr hc r r e r e. o tu 1!v s i l l b e .v ri l ' bh' ncgativc cvidcnc suppressed.Nei ' .rl .l . r, i iLr f t n pr oy id c fso f c .rc , !v h o tIL-rrersol1rsgencrallysufficicnrrorvafn i , rinr nr f r on, r lic rc c o rd o i p ri o r ranr dcsirucrnD or "ftrurnnrs" ot rhe rk.,rnr . r r . I r c r h. r s r h r fri o f rh .r.r.i s r J,..,i : , \ . r hc r wis cnn rv i i h b l c . In rl ,rt Own*hip of recotls ofttn becomcs .,... t hi r ec , , s nr v b c p rrti c u l a rl y rI i s s u ervhcn i n enrpl oyeeor i fde f. rtr) r r t hc nc x t t hc m p i s t.T h c th c r- p c rl e n tc rn trrctor,:rfrerw orki ngf,,r.n ,:.r,.f , r c nc nt c s r lt rc c o rd s n ra y rl s o !s e n o (.o n l rofi t) or l .,r i n) i n(l i vi cl .: , , ' f n ir r inr . nr n e c o i rh c rc c o s u x l o , e n ti i y,hrves rhee.rtl oyhent v()l -. ..:.r , t t o*r hLe iLr n rret| e rtrrc n t o f n l l u ri l y o r i s Ii red.l )oesrhc.l ep ti .l j :.. i .r : , . f r . \ { t ( t iiion .)l l y s, o o rc rrs n c d rc ra p i s tta kc thc fi l cs rvi th hrL?l )ocs 'l r rr r,r l\ J ( \ l|uf t |, r r J c t.rc \ p i rti c n l s rh e i r8 e n cyor othcr cnl i ry kcct i copy t :l ,cir f lr hr r , r & e c s s rh c i r n rc n trl o f (l re re coftl s?' l ' hernsw ers ro rl )ese (rre (i o n s dcrefd uron w hcrher rhe l )..,l i i , r . , i, J s .\ ! 1, , (li., ,y I e s rl ri n r.r) fi ri e rr d .ei dcsn) srxyrr rhe.grn.y (rl x. I .,, 1r, l( \ r , , , . r in, . i n ,l .l t,{ ,v c t,, h e i .mfl o y .r) rnJ hrvc r ncw tl rcnpi st ( , \ r ! rr!. , r , ir lr . r S,rft)()s rh e e rs s i s n c (lro rhr ci sc. ,n w herh., rhc t)i ,1 ... r rl r,r.rli\ r \ f f ( 1. , f hr \ I .,l n rh l n i l l l tl rx i i c n r (l c e i d.sn, l ervc rhe xscf.y i n(l ' .rr.rr\r lili\ / hf , ! ! ir l, r l tr l i .ri \i n g b o rftl . e rn ti ru e sto l t sccnby thc {.nrf r| cfr' l l ,i \ s , n, l( l i( l, x , l( r ( ) rh r 1 \o .f(ti l i h c fi s r i r . rcs' !1ri nA . rl r',.,t) i\ rl) . r J , lf s r ) y r ,l n ..(n k r y e rr Ir i s i n rportr!rtr) dctc,In c w honr i t| ro r l, . , . r f \ f n, l. , l . r.,1j rn rL (rr i h e rh c l )i ri .D t prI\ (rhe tn' i l i ns rhcri t,i \t ,)r th c .,.r,l()y.t) bfcr,,s(ofrf,, rhi rrs,i l l ri n i .rl r . hi. r f ( lr c r ( iy . ( trr{ )rrt,h i rri l l rs rL t.r. ! n. r hl. il { t ur Lf.h rl ,n s h i r? O r b c rh ( j ' $ s ,nr ,)r..rr! i h.rr" ow ,r\" tl k I fc ,n l ts .Il rhf f.rnl rr (l c.i dfi k,.,' )i i n t hr t lr r npis t J ts n rv s rc c rrJ s 1 i r[.rp' ri f,,. , ( . lr r , ) lr jr Lhf(rrr { ,)f i n N n ti c i ,( ttu .t,D c rr!!i rh rh. (l cpi rri ng rhfr.r.r!,,r r r h. t ur , il hr c ru s t th t d re rrp i rt ti \r, i i i s i D rfofri rr hI rhr rhrr.t]i srn) \.rrA n, r \ , ir ( l r r s r l) r i n Fi n c o frr. l n )th h rv ..r l e rsr r.ot)y (' l rhr frcofti s s,, ()rrl r. r hit r . \ . f , , . ui, ^ (,rd ,r.d s h o u l db c rh .r rfc rrm tnr i s n,,i i n' tri rtd. l -hr .u ,,:,i r l hv r er nog, rpo i c y tg ftl i n g rh c c rrp l o y e rshouklkrep rt l ei i t r c,)pyof rcL rl . r r, 1, . r r, r c r ionoI r e c o .d sw h e Dd ty rh c r.c o r(lsi ft i t i s i nrpoft.nrnrr rhcrn ...rh r lr f J . s r s nr r . d. s c . l h c .g r i s g e n - to hrve (locLrnurrrrrf r)i rhe rrlrttrrnt f,rl l \ ii. , r ! 1, . r ! 1nir n rl )e d ri c o f .l i s - rl r.r w .rsp rovi dedw hi l e the| rri enr l yrs .l ,.rr.:., r r r ef lr Ln. r r io nT.h e te rm;ri rri o n ;Dd rc i fc .re .In thr cvenirhrt drcprti ent l ,,,rc. ' ' l, onl, lht c r r ci u l l vd o c rn n e .te d . wrre ro (lrci.lc ro sr.y rt thc agcncyand ro s c ea n rt rhcrrhcrapi sr,rhf depl ti .s \r'r'h oO whs t he Re c o rd s ? th e p i s tu u rLl ortl i nari l ynot recd and \\'l ).r Lar I e t , r t ieni, n to n fe rm i n rri o n n o r b c e n ri dcdro trkc r .ory of rl rc ,,i rh i r t hr ions hip, rc q rc s rsrh .r rh e records ro his/hcr ncw locxrn,r- \Yere th d rpi' t Llr s t r ovall t r c rrn re n trc c o rd s ? th e frri e n t r) l rter ransttr frn the Ii r\e r l\ ent is r is c on s i l e re dto b c th c .gency Lrck ro ihe detaftins dlerrpist, .$ d rr , ) i t h. r , c or ds ,.s i s $ c c rs e i n I .of'y oi rheigcncl's reco scoul.ithen n ro sr r ur s . ll. r ions , tl c rl rc ra ti s t w i l l o rl r l l r c ll t he lar ic n r rh a r rh e re c o rc l s arcHlaDs.LG.LE,r.o.is an \ L l ln ,r tbe der r ov edi ,r " l r.m d e do v e r" AAMFT.on s! kant who \\'h rl . p iena of t er rh rv e .e rh ;i ri s h rs providesleqalcons!ltatlon r.rtri d, r s r c c e$ t o d re re c o rd s(e -c ., , re rr i, m r nd c or y i n s ), th e y o { ,rl h ' ro AA^4FTCllnlcalMembers. ]r.r\. n . , igl) r r o c on rF l d \e rrp i s tsr.) Toac.e$thisfreeservi.e, pleasev sit www aamft.org r.\i !r! { ir " f enr . r " . ll re c o .d s V/h . en g e n or.onta.t Rlchard at (853)4s6 0695. m al( c s uc r r r c q u e s rs th , e y trre n r \