Speaker 1: Welcome back, everybody.
Speaker 2: Today's topic we're going to look at is clinical records, documentation, HIPPA,
Speaker 2: and risk management. The EFP doesn't expect you to memorize
Speaker 2: every state's record retention statute, but they often test you
Speaker 2: with questions looking at principles governing good documentation, and can
Speaker 2: identify the best professional response. So why do psychologists keep
Speaker 2: clinical records? They serve several functions. They support continuity of treatment,
Speaker 2: document assessment, diagnosis and treatment, provide evidence of the psychologist's
Speaker 2: clinical reasoning, help another provider understand the client's treatment, facilitate
Speaker 2: communication among authorized providers, support insurance reimbursement, demonstrate compliance with
Speaker 2: ethical and legal standards, help psychologists remember important information and
Speaker 2: long term cases, and provide documentation if treatment is later
Speaker 2: reviewed by a licensing board or court. Think of the
Speaker 2: clinical record as a principal document that may eventually be
Speaker 2: reviewed by someone other than you, the psychologist. A good
Speaker 2: test is would I be comfortable explaining why I wrote
Speaker 2: this if the record were reviewed professionally. Good clinical records
Speaker 2: so generally to be accurate, objective, timely relevant, legible, organized,
Speaker 2: clinically useful, and professionally written, the psychologists should avoid unnecessary
Speaker 2: personal opinions, speculations, insults, or inflammatory language. An example of
Speaker 2: poor documentation would be client was completely irrational and manipulative
Speaker 2: compared to client raises voice several times during discussion of
Speaker 2: the treatment plan, interrupted repeatedly, and say that he would
Speaker 2: discontinue treatment. That's an observable behavior rather than of subjective label.
Speaker 2: One of the e TRIPO P rules, when possible, describe
Speaker 2: behavior rather than labeling the individual. Clinical notes should generally
Speaker 2: be completed as soon as reasonably possible after the session,
Speaker 2: ideally the same day. Delayed documentation creates several problems. Memory
Speaker 2: becomes less reliable, important details may be forgotten, and questions
Speaker 2: may arise regarding the accuracy of the record. Clinical examples
Speaker 2: a psychologist sees a client Monday, but waits three weeks
Speaker 2: before documenting the session. That's not very good at all.
Speaker 2: This creates the possibility that information from different sessions will
Speaker 2: be confused.
Speaker 1: When given a.
Speaker 2: Choice between writing notes weeks later or completing documentation promptly,
Speaker 2: that's the latter, is your answer. What belongs in the
Speaker 2: criminal clinical record is Common components include identifying information like
Speaker 2: the client name, data, birth, contact information, emergency contacts. This
Speaker 2: may include therapy agreement, fees, cancellation policies, limits of confidentiality,
Speaker 2: privacy notices, telehealth consent, session or progress notes. Typically document
Speaker 2: major topics discussed, relevant symptoms, interventions, client response changes and
Speaker 2: functioning changes in risk treatment progress. Treatment plan includes goals, objectives,
Speaker 2: treatment methods, expected timeframes, change it to the changes to
Speaker 2: the treatment strategy, itself assessment reports, document test administered relevant scores, interpretation,
Speaker 2: diagnostic conclusions. Correspondence includes consultation records, relevant emails, letters, and
Speaker 2: communication with other providers. The release of information is a
Speaker 2: valid authorization that should clearly identify what information may be
Speaker 2: disclosed into whom. Test data and test security psychologists must
Speaker 2: distinguish between ordinary clinical documentation and psychological testing materials. Testing
Speaker 2: information can include raw scores, response data, protocols, scoring materials.
Speaker 2: Sub Testing materials require additional protection because unrestricted a disclosure
Speaker 2: could compromise test security or test integrity. Here's an example,
Speaker 2: can you give me everything for my psychological assessment? The
Speaker 2: psychologists should not automatically hand over copyrighted test manuals, protected
Speaker 2: test materials, or secure testing content merely because the client
Speaker 2: requests it. A psychologists needs to consider ethical requirements HIPPA
Speaker 2: applicable law test security. Sometimes the Triple people trap you
Speaker 2: by saying clients' access rights do not automatically eliminate test
Speaker 2: security obligations. Clinical notes versus psychotherapy notes. This distinction is
Speaker 2: particularly important under HIPPA. Ordinary clinical records may contain information
Speaker 2: such as diagnosis, symptoms, treatment plan progress. Psychotherapy notes receive
Speaker 2: additional protection, generally referring notes reported by a mental health
Speaker 2: professional documenting or analyzing the contents of counseling confirm conversations
Speaker 2: that are kept separate, memory anchor psychotherapy notes equals separate
Speaker 2: plus specially protected. Do not assume that every progress note
Speaker 2: written by a therapist automatically qualifies as a HIPPA psychotherapy note.
Speaker 1: Objectivity and professional language is important.
Speaker 2: Avoid language that is speculative, again, judgmental, sarcastic, or inflammatory.
Speaker 2: An example, the client's husband is obviously a narcissist, It's
Speaker 2: better to say the client described as frequently criticizing or
Speaker 2: reporter that he threatened to lead the relationship again looking
Speaker 2: at the behavior, and the psychologist has never evaluated the husband.
Speaker 2: Diagnosing or labeling someone you have never evaluated introduces unnecessary speculation.
Speaker 2: Document what you know, not what you assume. Consistent terminology.
Speaker 2: Psychologists should use professional terminology consistency. This includes appropriate DSM
Speaker 2: diagnostic terminology, professional titles, treatment terminology, an example treating psychologists
Speaker 2: versus forensic evaluated versus consultants. This becomes important when legal
Speaker 2: proceedings are involved. Record retention. The material in your study
Speaker 2: pages emphasizes a commonly taught rule of retaining records for
Speaker 2: at least seven years up to the last professional contact,
Speaker 2: while recognizing that actual requirements very according to State eight
Speaker 2: client age licensing rules payer requirements, records involving minors often
Speaker 2: must be maintained for a longer period. If a question
Speaker 2: gives you a specific jurisdictional law, follow the law.
Speaker 1: Presented in the question.
Speaker 2: If no specific jurisdiction is provided, think in terms of
Speaker 2: the broader ethical principle. Maintain records for the legally and
Speaker 2: ethically required period and verify applicable jurisdictional requirements. Do not
Speaker 2: assume that one retention period applies universally. Records security Psychologists
Speaker 2: have an obligation to protect both physical and electronic records.
Speaker 2: Physical records may require locked cabinets, secure offices, controlled access
Speaker 2: proper destruction electronic records and must have passwords, encryption, access controls,
Speaker 2: secure backups. Access should be generally limited to authorize individuals
Speaker 2: who need the information. A psychologist keeps printed client records
Speaker 2: in an unlocked cabinet in a waiting room, even if
Speaker 2: nobody has actually read them. This represents inadequate protection of
Speaker 2: confidential information. Each triple P principles confidentially requires more than
Speaker 2: simply not intentionally telling people information. They also take reasonable
Speaker 2: steps to prevent unauthorized access. Another one is disposing of records.
Speaker 2: Paper records should be shredded, professionally destroyed, considerated when appropriate.
Speaker 2: Electronic records should be securely deleted or otherwise disposed of
Speaker 2: using appropriate safeguards. Simply throwing them away into ordinary trash
Speaker 2: would generally be inappropriate. HIPPA governs the handling of protected
Speaker 2: in from health information, but covered entities and their business associates.
Speaker 2: For each triple P purposes distinguish among several important concepts,
Speaker 2: a privacy rule, who may access or disclose information and
Speaker 2: under what circumstances?
Speaker 1: The security rule, how.
Speaker 2: Is electronic protected health information safeguarded? And breach notification. What
Speaker 2: happens when protected information has been improperly accessed, access to
Speaker 2: user disclosed noticey of Privacy practices. HIPPA covered providers general
Speaker 2: provide clients with notice of privacy practices. The notice explains
Speaker 2: issues such as how protected information may be used, how
Speaker 2: it may be disclosed, the client's privacy rights. Here's how
Speaker 2: your health information may be handled in what your privacy
Speaker 2: rights are As a memory anchor. The HIPPO security rule
Speaker 2: focuses specifically on electronic protected health information EPHI. Safeguards are
Speaker 2: commonly divided into three categories. Administrative safeguard, staff training.
Speaker 1: Security policies, access.
Speaker 2: Procedures, risk management, physical safeguards, secure workstations, facility access controls,
Speaker 2: device protection, and finally, technical safeguards access controls, unique user identification,
Speaker 2: audit mechanisms, appropriate technical protection of electronic information. So think
Speaker 2: of APT, administrative, physical, technical for the memory trick in
Speaker 2: regards to.
Speaker 1: HIPPA security rules. How about business associates?
Speaker 2: Well, Psychologists may use outside organizations that handle PHI examples
Speaker 2: and could include building companies, certain cloud storage providers, electronic
Speaker 2: health record vendors. When an organization qualifies as a hip
Speaker 2: Hop business associate, an appropriate business associate agreement is generally required.
Speaker 1: Psychologists decides, for instance, to store.
Speaker 2: Patient records using an online service, the psychologists should not
Speaker 2: think it has a password, so HIPPA is handled. Instead,
Speaker 2: the psychologists must determine whether the service appropriately handles PHI
Speaker 2: and whether a BAA is required and available. Convenience does
Speaker 2: not override confidentiality requirements. HIPPA breaches when protected information is
Speaker 2: improperly accessed to user disclosed. The psychologists must determine whether
Speaker 2: the situation constitutes a reportable breach and follow the applicable
Speaker 2: notification requirements. Potential responsibilities can include investigating what occurred, mitigating harm,
Speaker 2: documenting the incident, notifying affected individuals, and making required government notifications.
Speaker 2: An example, psychologists accidentally emails a clinical report to the
Speaker 2: wrong person. The psychologists should not simply delete the email
Speaker 2: I hope nothing happens. The situation should be evaluated according
Speaker 2: to HIPPOP breach procedures when confidential When confidentiality has been
Speaker 2: potentially compromised, do not conceal the error, evaluate document, mitigate,
Speaker 2: and follow legal and ethical procedures.
Speaker 1: Next is high risk clients.
Speaker 2: Documentation becomes extremely important when they are safety concerns, suicidal ideation,
Speaker 2: homicidal threats, serious self harm, violent risk, abuse, or neglect.
Speaker 2: Documentation should capture the psychologists assessment of clinical reasoning, not
Speaker 2: merely the conclusion.
Speaker 1: Example.
Speaker 2: Weak documentation client is not suicidal. Better documentation would describe
Speaker 2: relevant information, presence or absence of suicidal ideation, intent, plan
Speaker 2: means relevant history, protective factors, risk factors, clinical judgment, document
Speaker 2: the reasoning, not merely the conclusion. Clinical example suicide risk
Speaker 2: client says, sometimes I think everyone would be better off
Speaker 2: without me. Psychologists asks about suicidal thoughts, plan intent, access
Speaker 2: to means previous attempts, substance use, social support, reasons for living,
Speaker 2: and other.
Speaker 1: Relevant risk and protect the factors.
Speaker 2: The client denies intent or plan and identifies several strong
Speaker 2: protective factors. The psychologist determines that outpatient treatment remains appropriate
Speaker 2: and creates safety.
Speaker 1: Follow up plan.
Speaker 2: But the client reported with the psychologists assessed relevant risk,
Speaker 2: protecting factors and clinical judgment intervention, and then a followable
Speaker 2: plan creates a defensible chain of reasoning. Repeat it with
Speaker 2: the client reported first part of the chain with the
Speaker 2: psychologists assessed the relevant risk, the protective factors, clinical judgment, intervention,
Speaker 2: and the.
Speaker 1: Follow up plan.
Speaker 2: Next is consultation and documentation. Consultation can be particularly important
Speaker 2: when dealing with again suicide risk, violent risk, bound problems,
Speaker 2: legal uncertainty, complex ethical issues. An example is a psychologist
Speaker 2: is uncertain whether a client's threat toward another person requires
Speaker 2: protective action. The psychologist should consult appropriately and review applicable lethal, legal,
Speaker 2: and ethical obligations. Documenting the consultation helps demonstrate the psychologists
Speaker 2: engaged in reason to professional decision making rather than acting impulsively.
Speaker 2: Court involved cases assume clinical records may eventually be subpeded,
Speaker 2: reviewed by attorneys, examined by a licensing board discussed in court.
Speaker 1: This does not mean.
Speaker 2: Psychologist should write defensively or omit clinically necessary information. It
Speaker 2: means records should remain professional and clinically relevant. Avoid speculation
Speaker 2: about guilt, unsupported conclusions, personal attacks, unnecessary legal opinions, a
Speaker 2: bad examples and fathers clearly lying about the custody dispute
Speaker 2: better as father's account of the incident differed from the
Speaker 2: account providing the collateral documentation, a psychologist describes a discrepancy
Speaker 2: without without unsupported determination. Another area is therapists versus forensic evaluator.
Speaker 2: One of the most important role boundary issues because when
Speaker 2: a treating psychologist becomes involved in legal proceedings, things change.
Speaker 2: Treatment and forensic evaluation involved totally different roles. In treating
Speaker 2: psychologists' primary responsibility is treatment. Forensic evaluators answering a psycho
Speaker 2: legal question. An example, a therapy client involved in a
Speaker 2: custody dispute asks, can you evaluate both of us and
Speaker 2: tell the judge that I should get custody? Psychologists should
Speaker 2: recognize the potential role conflict providing therapy does not automatically
Speaker 2: qualify or position the psychologists to perform an independent custody evaluation.
Speaker 2: You must clarify the roles and avoid incompatible multiple relationships. Next,
Speaker 2: we're going to go to telehealth documentation. I know it's
Speaker 2: getting a little long, sorry, folks. Telehealth creates additional documentation
Speaker 2: considerations to depending on jurisdiction and circumstances, records may appropriately
Speaker 2: include client location, psychologists, location technology used, relevant technical disruptions,
Speaker 2: confirmation of identity, and appropriate telehealth consent safety arrangements emergency procedures.
Speaker 2: Suppose the client says during video therapy of going to
Speaker 2: kill myself, the location matters. The psychologist needs to know
Speaker 2: where the client is physically to coordinate emergency intervention if necessary.
Speaker 2: Location can also matter for licensure and jurisdictional requirements. So
Speaker 2: here's another chain of the important identity plus location plus
Speaker 2: privacy plus technology plus emergency planning plus jurisdiction.
Speaker 1: Those are the good chain for telehealth.
Speaker 2: Client access to records generally, clients generally have significant rights
Speaker 2: regarding access to the health information, but exceptions exist. Important
Speaker 2: concepts include rights to request access, request amendment information, and
Speaker 2: obtain information concerning certain disclosures. However, access rights are not unlimited.
Speaker 2: Special rules may apply to psychotherapy notes, information involving third parties,
Speaker 2: certain safety concerns, certain legal proceedings, test materials.
Speaker 1: And miners.
Speaker 2: Do not answer an ants do not choose an answer
Speaker 2: simply stating the psychologist owns the record, therefore the client
Speaker 2: cannot see it. Physical ownership of record does not eliminated
Speaker 2: clients legal access rights, and be careful in request to
Speaker 2: amend records. A client may disagree with something document in
Speaker 2: the record. The psychologists generally should not simply erase or
Speaker 2: rewrite history to make the client happy.
Speaker 1: Preserve record integrity.
Speaker 2: Corrections and amendments should be handled transparently according to applicable requirements.
Speaker 2: Records involving miners can become complicated because several parties may
Speaker 2: have interests or rights involving treatment information.
Speaker 1: Who consent it to treatment? Who holds legal authority?
Speaker 2: Does the miner have confidentiality protections? Are parents entitled to
Speaker 2: particular information? Could disclosure harm treatment? What does state law require?
Speaker 2: Do not assume parent equals automatic unrestricted access, nor should
Speaker 2: you assume minor equals complete confidentiality. The correct answer often
Speaker 2: requires considering law informed consent, the minor status, clinical warfare.
Speaker 1: I'm sorry, let me repeat everything.
Speaker 2: The correct answer often requires considering the law informed consent,
Speaker 2: the minor status, clinical welfare, and the circumstances of treatment.
Speaker 1: More is not always better.
Speaker 2: A common misconception is the safest psychologist writes down absolutely
Speaker 2: everything not necessarily. Excessive documentation can create ethical and clinical problems.
Speaker 2: Avoid recording irrelevant sexual details, gossip, personal judgments, unnecessary family
Speaker 2: information speculation. If a client spends twenty minutes describing an
Speaker 2: argument with the sibling, the psychologists not need to create
Speaker 2: a word for word transcript of it. Just use something
Speaker 2: like client discussed ongoing conflict dis sibling next is going
Speaker 2: to be the minimum necessary idea useful Hippo concepts is
Speaker 2: that when the minimum necessary standard applies, disclosures should be
Speaker 2: generally limited to information reasonably necessary to accomplish the attended purpose.
Speaker 2: So you should ask yourself what information is actually needed
Speaker 2: for this legitimate purpose. Clinical documentation formula for many E
Speaker 2: triple P scenarios. Think of ar iop SO assessment. What
Speaker 2: clinically relevant information did you obtain? Are for reasoning? How
Speaker 2: did you interpret it? I for intervention?
Speaker 1: What did you do? OH? Outcome? How do the client respond?
Speaker 1: And P? What happens next? The plant so ar iop.
Speaker 2: SO client reports depressed symptoms and passive thoughts of death
Speaker 2: assessment Suicide risk assessment completed. Client denies plan or intent
Speaker 2: reasoning current presentation does not indicate need for emergency hospitalization
Speaker 2: and invention safety planning completed. Outcome, Client participates appropriately and
Speaker 2: agrees to use identified supports and plan. Follow up scheduled
Speaker 2: and will be reassessed. High yield Each triple P decision
Speaker 2: rules document clinically relevant facts, prefer objective descriptions, document important
Speaker 2: clinical reasoning, protect confidentiality, know your role, know your jurisdiction,
Speaker 2: and that's it for now, folks, I know it's a
Speaker 2: little long, but we'll have some practice questions later that
Speaker 2: During the week,