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<v Speaker 1>Welcome back, everybody.

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<v Speaker 2>Today's topic we're going to look at is clinical records, documentation, HIPPA,

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<v Speaker 2>and risk management. The EFP doesn't expect you to memorize

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<v Speaker 2>every state's record retention statute, but they often test you

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<v Speaker 2>with questions looking at principles governing good documentation, and can

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<v Speaker 2>identify the best professional response. So why do psychologists keep

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<v Speaker 2>clinical records? They serve several functions. They support continuity of treatment,

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<v Speaker 2>document assessment, diagnosis and treatment, provide evidence of the psychologist's

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<v Speaker 2>clinical reasoning, help another provider understand the client's treatment, facilitate

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<v Speaker 2>communication among authorized providers, support insurance reimbursement, demonstrate compliance with

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<v Speaker 2>ethical and legal standards, help psychologists remember important information and

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<v Speaker 2>long term cases, and provide documentation if treatment is later

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<v Speaker 2>reviewed by a licensing board or court. Think of the

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<v Speaker 2>clinical record as a principal document that may eventually be

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<v Speaker 2>reviewed by someone other than you, the psychologist. A good

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<v Speaker 2>test is would I be comfortable explaining why I wrote

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<v Speaker 2>this if the record were reviewed professionally. Good clinical records

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<v Speaker 2>so generally to be accurate, objective, timely relevant, legible, organized,

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<v Speaker 2>clinically useful, and professionally written, the psychologists should avoid unnecessary

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<v Speaker 2>personal opinions, speculations, insults, or inflammatory language. An example of

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<v Speaker 2>poor documentation would be client was completely irrational and manipulative

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<v Speaker 2>compared to client raises voice several times during discussion of

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<v Speaker 2>the treatment plan, interrupted repeatedly, and say that he would

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<v Speaker 2>discontinue treatment. That's an observable behavior rather than of subjective label.

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<v Speaker 2>One of the e TRIPO P rules, when possible, describe

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<v Speaker 2>behavior rather than labeling the individual. Clinical notes should generally

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<v Speaker 2>be completed as soon as reasonably possible after the session,

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<v Speaker 2>ideally the same day. Delayed documentation creates several problems. Memory

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<v Speaker 2>becomes less reliable, important details may be forgotten, and questions

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<v Speaker 2>may arise regarding the accuracy of the record. Clinical examples

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<v Speaker 2>a psychologist sees a client Monday, but waits three weeks

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<v Speaker 2>before documenting the session. That's not very good at all.

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<v Speaker 2>This creates the possibility that information from different sessions will

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<v Speaker 2>be confused.

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<v Speaker 1>When given a.

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<v Speaker 2>Choice between writing notes weeks later or completing documentation promptly,

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<v Speaker 2>that's the latter, is your answer. What belongs in the

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<v Speaker 2>criminal clinical record is Common components include identifying information like

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<v Speaker 2>the client name, data, birth, contact information, emergency contacts. This

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<v Speaker 2>may include therapy agreement, fees, cancellation policies, limits of confidentiality,

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<v Speaker 2>privacy notices, telehealth consent, session or progress notes. Typically document

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<v Speaker 2>major topics discussed, relevant symptoms, interventions, client response changes and

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<v Speaker 2>functioning changes in risk treatment progress. Treatment plan includes goals, objectives,

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<v Speaker 2>treatment methods, expected timeframes, change it to the changes to

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<v Speaker 2>the treatment strategy, itself assessment reports, document test administered relevant scores, interpretation,

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<v Speaker 2>diagnostic conclusions. Correspondence includes consultation records, relevant emails, letters, and

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<v Speaker 2>communication with other providers. The release of information is a

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<v Speaker 2>valid authorization that should clearly identify what information may be

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<v Speaker 2>disclosed into whom. Test data and test security psychologists must

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<v Speaker 2>distinguish between ordinary clinical documentation and psychological testing materials. Testing

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<v Speaker 2>information can include raw scores, response data, protocols, scoring materials.

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<v Speaker 2>Sub Testing materials require additional protection because unrestricted a disclosure

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<v Speaker 2>could compromise test security or test integrity. Here's an example,

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<v Speaker 2>can you give me everything for my psychological assessment? The

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<v Speaker 2>psychologists should not automatically hand over copyrighted test manuals, protected

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<v Speaker 2>test materials, or secure testing content merely because the client

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<v Speaker 2>requests it. A psychologists needs to consider ethical requirements HIPPA

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<v Speaker 2>applicable law test security. Sometimes the Triple people trap you

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<v Speaker 2>by saying clients' access rights do not automatically eliminate test

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<v Speaker 2>security obligations. Clinical notes versus psychotherapy notes. This distinction is

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<v Speaker 2>particularly important under HIPPA. Ordinary clinical records may contain information

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<v Speaker 2>such as diagnosis, symptoms, treatment plan progress. Psychotherapy notes receive

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<v Speaker 2>additional protection, generally referring notes reported by a mental health

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<v Speaker 2>professional documenting or analyzing the contents of counseling confirm conversations

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<v Speaker 2>that are kept separate, memory anchor psychotherapy notes equals separate

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<v Speaker 2>plus specially protected. Do not assume that every progress note

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<v Speaker 2>written by a therapist automatically qualifies as a HIPPA psychotherapy note.

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<v Speaker 1>Objectivity and professional language is important.

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<v Speaker 2>Avoid language that is speculative, again, judgmental, sarcastic, or inflammatory.

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<v Speaker 2>An example, the client's husband is obviously a narcissist, It's

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<v Speaker 2>better to say the client described as frequently criticizing or

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<v Speaker 2>reporter that he threatened to lead the relationship again looking

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<v Speaker 2>at the behavior, and the psychologist has never evaluated the husband.

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<v Speaker 2>Diagnosing or labeling someone you have never evaluated introduces unnecessary speculation.

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<v Speaker 2>Document what you know, not what you assume. Consistent terminology.

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<v Speaker 2>Psychologists should use professional terminology consistency. This includes appropriate DSM

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<v Speaker 2>diagnostic terminology, professional titles, treatment terminology, an example treating psychologists

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<v Speaker 2>versus forensic evaluated versus consultants. This becomes important when legal

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<v Speaker 2>proceedings are involved. Record retention. The material in your study

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<v Speaker 2>pages emphasizes a commonly taught rule of retaining records for

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<v Speaker 2>at least seven years up to the last professional contact,

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<v Speaker 2>while recognizing that actual requirements very according to State eight

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<v Speaker 2>client age licensing rules payer requirements, records involving minors often

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<v Speaker 2>must be maintained for a longer period. If a question

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<v Speaker 2>gives you a specific jurisdictional law, follow the law.

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<v Speaker 1>Presented in the question.

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<v Speaker 2>If no specific jurisdiction is provided, think in terms of

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<v Speaker 2>the broader ethical principle. Maintain records for the legally and

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<v Speaker 2>ethically required period and verify applicable jurisdictional requirements. Do not

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<v Speaker 2>assume that one retention period applies universally. Records security Psychologists

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<v Speaker 2>have an obligation to protect both physical and electronic records.

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<v Speaker 2>Physical records may require locked cabinets, secure offices, controlled access

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<v Speaker 2>proper destruction electronic records and must have passwords, encryption, access controls,

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<v Speaker 2>secure backups. Access should be generally limited to authorize individuals

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<v Speaker 2>who need the information. A psychologist keeps printed client records

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<v Speaker 2>in an unlocked cabinet in a waiting room, even if

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<v Speaker 2>nobody has actually read them. This represents inadequate protection of

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<v Speaker 2>confidential information. Each triple P principles confidentially requires more than

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<v Speaker 2>simply not intentionally telling people information. They also take reasonable

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<v Speaker 2>steps to prevent unauthorized access. Another one is disposing of records.

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<v Speaker 2>Paper records should be shredded, professionally destroyed, considerated when appropriate.

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<v Speaker 2>Electronic records should be securely deleted or otherwise disposed of

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<v Speaker 2>using appropriate safeguards. Simply throwing them away into ordinary trash

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<v Speaker 2>would generally be inappropriate. HIPPA governs the handling of protected

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<v Speaker 2>in from health information, but covered entities and their business associates.

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<v Speaker 2>For each triple P purposes distinguish among several important concepts,

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<v Speaker 2>a privacy rule, who may access or disclose information and

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<v Speaker 2>under what circumstances?

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<v Speaker 1>The security rule, how.

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<v Speaker 2>Is electronic protected health information safeguarded? And breach notification. What

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<v Speaker 2>happens when protected information has been improperly accessed, access to

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<v Speaker 2>user disclosed noticey of Privacy practices. HIPPA covered providers general

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<v Speaker 2>provide clients with notice of privacy practices. The notice explains

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<v Speaker 2>issues such as how protected information may be used, how

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<v Speaker 2>it may be disclosed, the client's privacy rights. Here's how

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<v Speaker 2>your health information may be handled in what your privacy

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<v Speaker 2>rights are As a memory anchor. The HIPPO security rule

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<v Speaker 2>focuses specifically on electronic protected health information EPHI. Safeguards are

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<v Speaker 2>commonly divided into three categories. Administrative safeguard, staff training.

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<v Speaker 1>Security policies, access.

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<v Speaker 2>Procedures, risk management, physical safeguards, secure workstations, facility access controls,

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<v Speaker 2>device protection, and finally, technical safeguards access controls, unique user identification,

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<v Speaker 2>audit mechanisms, appropriate technical protection of electronic information. So think

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<v Speaker 2>of APT, administrative, physical, technical for the memory trick in

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<v Speaker 2>regards to.

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<v Speaker 1>HIPPA security rules. How about business associates?

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<v Speaker 2>Well, Psychologists may use outside organizations that handle PHI examples

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<v Speaker 2>and could include building companies, certain cloud storage providers, electronic

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<v Speaker 2>health record vendors. When an organization qualifies as a hip

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<v Speaker 2>Hop business associate, an appropriate business associate agreement is generally required.

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<v Speaker 1>Psychologists decides, for instance, to store.

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<v Speaker 2>Patient records using an online service, the psychologists should not

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<v Speaker 2>think it has a password, so HIPPA is handled. Instead,

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<v Speaker 2>the psychologists must determine whether the service appropriately handles PHI

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<v Speaker 2>and whether a BAA is required and available. Convenience does

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<v Speaker 2>not override confidentiality requirements. HIPPA breaches when protected information is

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<v Speaker 2>improperly accessed to user disclosed. The psychologists must determine whether

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<v Speaker 2>the situation constitutes a reportable breach and follow the applicable

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<v Speaker 2>notification requirements. Potential responsibilities can include investigating what occurred, mitigating harm,

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<v Speaker 2>documenting the incident, notifying affected individuals, and making required government notifications.

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<v Speaker 2>An example, psychologists accidentally emails a clinical report to the

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<v Speaker 2>wrong person. The psychologists should not simply delete the email

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<v Speaker 2>I hope nothing happens. The situation should be evaluated according

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<v Speaker 2>to HIPPOP breach procedures when confidential When confidentiality has been

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<v Speaker 2>potentially compromised, do not conceal the error, evaluate document, mitigate,

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<v Speaker 2>and follow legal and ethical procedures.

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<v Speaker 1>Next is high risk clients.

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<v Speaker 2>Documentation becomes extremely important when they are safety concerns, suicidal ideation,

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<v Speaker 2>homicidal threats, serious self harm, violent risk, abuse, or neglect.

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<v Speaker 2>Documentation should capture the psychologists assessment of clinical reasoning, not

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<v Speaker 2>merely the conclusion.

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<v Speaker 1>Example.

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<v Speaker 2>Weak documentation client is not suicidal. Better documentation would describe

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<v Speaker 2>relevant information, presence or absence of suicidal ideation, intent, plan

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<v Speaker 2>means relevant history, protective factors, risk factors, clinical judgment, document

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<v Speaker 2>the reasoning, not merely the conclusion. Clinical example suicide risk

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<v Speaker 2>client says, sometimes I think everyone would be better off

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<v Speaker 2>without me. Psychologists asks about suicidal thoughts, plan intent, access

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<v Speaker 2>to means previous attempts, substance use, social support, reasons for living,

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<v Speaker 2>and other.

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<v Speaker 1>Relevant risk and protect the factors.

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<v Speaker 2>The client denies intent or plan and identifies several strong

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<v Speaker 2>protective factors. The psychologist determines that outpatient treatment remains appropriate

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<v Speaker 2>and creates safety.

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<v Speaker 1>Follow up plan.

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<v Speaker 2>But the client reported with the psychologists assessed relevant risk,

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<v Speaker 2>protecting factors and clinical judgment intervention, and then a followable

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<v Speaker 2>plan creates a defensible chain of reasoning. Repeat it with

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<v Speaker 2>the client reported first part of the chain with the

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<v Speaker 2>psychologists assessed the relevant risk, the protective factors, clinical judgment, intervention,

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<v Speaker 2>and the.

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<v Speaker 1>Follow up plan.

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<v Speaker 2>Next is consultation and documentation. Consultation can be particularly important

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<v Speaker 2>when dealing with again suicide risk, violent risk, bound problems,

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<v Speaker 2>legal uncertainty, complex ethical issues. An example is a psychologist

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<v Speaker 2>is uncertain whether a client's threat toward another person requires

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<v Speaker 2>protective action. The psychologist should consult appropriately and review applicable lethal, legal,

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<v Speaker 2>and ethical obligations. Documenting the consultation helps demonstrate the psychologists

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<v Speaker 2>engaged in reason to professional decision making rather than acting impulsively.

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<v Speaker 2>Court involved cases assume clinical records may eventually be subpeded,

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<v Speaker 2>reviewed by attorneys, examined by a licensing board discussed in court.

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<v Speaker 1>This does not mean.

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<v Speaker 2>Psychologist should write defensively or omit clinically necessary information. It

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<v Speaker 2>means records should remain professional and clinically relevant. Avoid speculation

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<v Speaker 2>about guilt, unsupported conclusions, personal attacks, unnecessary legal opinions, a

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<v Speaker 2>bad examples and fathers clearly lying about the custody dispute

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<v Speaker 2>better as father's account of the incident differed from the

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<v Speaker 2>account providing the collateral documentation, a psychologist describes a discrepancy

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<v Speaker 2>without without unsupported determination. Another area is therapists versus forensic evaluator.

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<v Speaker 2>One of the most important role boundary issues because when

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<v Speaker 2>a treating psychologist becomes involved in legal proceedings, things change.

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<v Speaker 2>Treatment and forensic evaluation involved totally different roles. In treating

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<v Speaker 2>psychologists' primary responsibility is treatment. Forensic evaluators answering a psycho

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<v Speaker 2>legal question. An example, a therapy client involved in a

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<v Speaker 2>custody dispute asks, can you evaluate both of us and

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<v Speaker 2>tell the judge that I should get custody? Psychologists should

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<v Speaker 2>recognize the potential role conflict providing therapy does not automatically

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<v Speaker 2>qualify or position the psychologists to perform an independent custody evaluation.

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<v Speaker 2>You must clarify the roles and avoid incompatible multiple relationships. Next,

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<v Speaker 2>we're going to go to telehealth documentation. I know it's

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<v Speaker 2>getting a little long, sorry, folks. Telehealth creates additional documentation

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<v Speaker 2>considerations to depending on jurisdiction and circumstances, records may appropriately

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<v Speaker 2>include client location, psychologists, location technology used, relevant technical disruptions,

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<v Speaker 2>confirmation of identity, and appropriate telehealth consent safety arrangements emergency procedures.

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<v Speaker 2>Suppose the client says during video therapy of going to

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<v Speaker 2>kill myself, the location matters. The psychologist needs to know

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<v Speaker 2>where the client is physically to coordinate emergency intervention if necessary.

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<v Speaker 2>Location can also matter for licensure and jurisdictional requirements. So

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<v Speaker 2>here's another chain of the important identity plus location plus

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<v Speaker 2>privacy plus technology plus emergency planning plus jurisdiction.

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<v Speaker 1>Those are the good chain for telehealth.

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<v Speaker 2>Client access to records generally, clients generally have significant rights

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<v Speaker 2>regarding access to the health information, but exceptions exist. Important

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<v Speaker 2>concepts include rights to request access, request amendment information, and

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<v Speaker 2>obtain information concerning certain disclosures. However, access rights are not unlimited.

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<v Speaker 2>Special rules may apply to psychotherapy notes, information involving third parties,

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<v Speaker 2>certain safety concerns, certain legal proceedings, test materials.

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<v Speaker 1>And miners.

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<v Speaker 2>Do not answer an ants do not choose an answer

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<v Speaker 2>simply stating the psychologist owns the record, therefore the client

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<v Speaker 2>cannot see it. Physical ownership of record does not eliminated

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<v Speaker 2>clients legal access rights, and be careful in request to

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<v Speaker 2>amend records. A client may disagree with something document in

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<v Speaker 2>the record. The psychologists generally should not simply erase or

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<v Speaker 2>rewrite history to make the client happy.

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<v Speaker 1>Preserve record integrity.

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<v Speaker 2>Corrections and amendments should be handled transparently according to applicable requirements.

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<v Speaker 2>Records involving miners can become complicated because several parties may

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<v Speaker 2>have interests or rights involving treatment information.

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<v Speaker 1>Who consent it to treatment? Who holds legal authority?

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<v Speaker 2>Does the miner have confidentiality protections? Are parents entitled to

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<v Speaker 2>particular information? Could disclosure harm treatment? What does state law require?

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<v Speaker 2>Do not assume parent equals automatic unrestricted access, nor should

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<v Speaker 2>you assume minor equals complete confidentiality. The correct answer often

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<v Speaker 2>requires considering law informed consent, the minor status, clinical warfare.

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<v Speaker 1>I'm sorry, let me repeat everything.

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<v Speaker 2>The correct answer often requires considering the law informed consent,

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<v Speaker 2>the minor status, clinical welfare, and the circumstances of treatment.

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<v Speaker 1>More is not always better.

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<v Speaker 2>A common misconception is the safest psychologist writes down absolutely

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<v Speaker 2>everything not necessarily. Excessive documentation can create ethical and clinical problems.

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<v Speaker 2>Avoid recording irrelevant sexual details, gossip, personal judgments, unnecessary family

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<v Speaker 2>information speculation. If a client spends twenty minutes describing an

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<v Speaker 2>argument with the sibling, the psychologists not need to create

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<v Speaker 2>a word for word transcript of it. Just use something

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<v Speaker 2>like client discussed ongoing conflict dis sibling next is going

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<v Speaker 2>to be the minimum necessary idea useful Hippo concepts is

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<v Speaker 2>that when the minimum necessary standard applies, disclosures should be

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<v Speaker 2>generally limited to information reasonably necessary to accomplish the attended purpose.

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<v Speaker 2>So you should ask yourself what information is actually needed

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<v Speaker 2>for this legitimate purpose. Clinical documentation formula for many E

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<v Speaker 2>triple P scenarios. Think of ar iop SO assessment. What

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<v Speaker 2>clinically relevant information did you obtain? Are for reasoning? How

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<v Speaker 2>did you interpret it? I for intervention?

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<v Speaker 1>What did you do? OH? Outcome? How do the client respond?

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<v Speaker 1>And P? What happens next? The plant so ar iop.

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<v Speaker 2>SO client reports depressed symptoms and passive thoughts of death

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<v Speaker 2>assessment Suicide risk assessment completed. Client denies plan or intent

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<v Speaker 2>reasoning current presentation does not indicate need for emergency hospitalization

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<v Speaker 2>and invention safety planning completed. Outcome, Client participates appropriately and

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<v Speaker 2>agrees to use identified supports and plan. Follow up scheduled

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<v Speaker 2>and will be reassessed. High yield Each triple P decision

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<v Speaker 2>rules document clinically relevant facts, prefer objective descriptions, document important

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<v Speaker 2>clinical reasoning, protect confidentiality, know your role, know your jurisdiction,

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<v Speaker 2>and that's it for now, folks, I know it's a

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<v Speaker 2>little long, but we'll have some practice questions later that

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<v Speaker 2>During the week,