Ohio Administrative Code › Title 4757 - Counselor, Social Worker, and Marriage and Family Therapist Board › Chapter 4757-5 - Code of Ethics › Section 4757-5-09 - Standards of ethical practice and professional conduct: record keeping

Current through all regulations passed and filed through July 1, 2024
(A)
			 Record keeping requirements: For each client/consumer of services, a licensee
			 or registrant shall keep records and case notes of the dates of counseling,
			 social work, marriage and family therapy , art therapy, and music therapy services;
			 types of counseling, social work, marriage and family therapy, art therapy, or
			 music therapy services; 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) Licensees
			 and registrants 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; treatment plan, revisions to the treatment plan,
			 correspondence, individual service plans, in-take assessments, informed consent
			 documents, and releases of information documents. All notes regarding a
			 client(s) must be developed and approved by the licensee or registrant and
			 shall not be the sole work product of any other person or software/information
			 technology system.
(C) Licensees
			 and registrants 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) Licensee or registrant 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) Licensees
			 and registrants 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)
								If storing
			 clinically relevant original artwork is not possible owing to storage space
			 limitations or the type of art work, a photographic representation should be
			 maintained.
(G)
								Upon termination of services, art produced by a client
			 that is not retained by the client may be disposed of by the licensee if the
			 licensee documents reasonable attempts to contact the client regarding taking
			 possession of the art work and if the licensee has retained a record of any
			 clinically relevant art work as described in paragraph (F) of this
			 rule.
(H)
								Art therapists and music therapists shall take into
			 consideration the benefits and potential negative impact of photographing,
			 videotaping, using other means to duplicate, and/or display or broadcast client
			 artwork with the client's best interest in mind. Art therapists and music
			 therapists shall provide to the client and/or parent or legal guardian clear
			 warnings about the therapist's inability to protect against the use, misuse,
			 and republication of the art or music product and/or session by others once it
			 is displayed or posted.
(I)
								Licensees and registrants shall obtain written informed
			 consent from a client, or when applicable, a parent or legal guardian, before
			 photographing the client's art expressions, making video or audio recordings,
			 otherwise duplicating, or permitting third-party observation of art or music
			 therapy sessions.
(J)
								Art therapists shall not make or permit any public use
			 or reproduction of a client's art therapy sessions, including verbalization and
			 art expression, without express written consent of the client or the client's
			 parent or legal guardian.
(K) Requirements
			 regarding client access to records are established in section
			 3701.74 of the Revised Code.
			 Licensees and registrants shall provide clients with reasonable access to
			 records concerning the client. Licensees and registrants 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 licensee or registrant
			 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.
(L) A licensee or
			 registrant shall not condone, partake, or assist in billing irregularities with
			 respect to insurance companies or direct billing.
(M) Licensees and
			 registrants 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.
(N) When licensees and
			 registrants leave a practice, they shall follow a prepared plan for transfer of
			 clients and files. Licensees and registrants, with the exception of registered
			 social work assistants and registered trainees, 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.