Code of Massachusetts Regulations › 262 CMR - BOARD OF ALLIED MENTAL HEALTH AND HUMAN SERVICES PROFESSIONS › Title 262 CMR 8.00 - Ethical Codes And Standards Of Conduct › Section 8.02 - Standards of Conduct Applicable to all Allied Mental Health Practitioners Licensed by the Board of Allied Mental Health and Human Services Professions

Current through Register 1525, July 5, 2024
(1)
Treatment Records
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(a) A licensee shall create and maintain a treatment record for each client which meets the standards of usual and customary practice.
(b) The licensee must maintain a client's treatment record for a minimum period of seven years from the date of the client's last professional contact with the licensee and in a manner which permits the former client or a successor licensee access to the record within the terms of 262 CMR. In the event that the client is a minor, the licensee must maintain the client's record for at least one year after the client has reached the age of majority as defined in M.G.L. c. 4, § 7, but in no event shall the record be retained for less than seven years.
(c) Upon commencing services, licensees shall notify clients in writing that treatment records will be maintained and the manner in which clients or authorized representatives may inspect treatment records. Licensees shall adhere to the following practices:
1. upon written request and within a reasonable period of time, licensees shall provide the client or authorized representative of the client a copy of such client's treatment record, pursuant to M.G.L. c. 112, § 12CC;
2. licensees may decline to permit a client or the client's authorized representative to inspect or obtain a copy of his or her treatment record if the licensee, in the reasonable exercise of his or her professional judgment, believes that allowing that client or the client's authorized representative to inspect or copy his or her treatment record would adversely affect the physical or mental well-being of that client; and
3. if a licensee declines to provide a copy of a client's treatment record to that client or the client's authorized representative pursuant to 262 CMR 8.02(1)(c)2., the licensee shall provide that client with a treatment summary in lieu of the full treatment record. If after receiving the treatment summary the client continues to request a copy of the full treatment record, the licensee shall provide a copy of the full treatment record to either an attorney designated by the client or a psychotherapist, as defined in M.G.L. c. 112, § 12CC designated by that client.
(d) licensee may not require payment of any balance due for prior professional services rendered to the client as a pre-condition for making the treatment records available. A licensee may charge a reasonable fee for copying of treatment records and postage where applicable.
(e) Licensees shall protect confidentiality, in accordance with applicable regulations and laws, in the creation, maintenance, storage, transfer and disposal of client records and in the event of withdrawal from practice or death of the licensee.
(f) Licensees shall comply with all state and federal laws regarding the creation, maintenance, storage, transfer, and disposal of treatment records.