A Guide to Record Keeping

There are both State Regulations and practice standards that govern proper record keeping. This brief guide first describes the State Regulations that are the minimum requirements for record keeping in Connecticut. Following the description of the Regulations we have provided those sections of the NASW Code of Ethics that relate to record keeping and additional suggestions on what should constitute a client record for prudent practice.

IT IS IMPORTANT TO NOTE THAT CLIENT RECORDS MUST BE KEPT AND MAINTAINED IN ACCORDANCE WITH THE STATE REGULATIONS. SOCIAL WORKERS WHO CHOOSE NOT TO KEEP RECORDS RISK SANCTIONING BY THE STATE OF CONNECTICUT, DEPARTMENT OF PUBLIC HEALTH’S PROFESSIONAL LICENSING DIVISION. SUCH SANCTIONING MAY INCLUDE FINANCIAL PENALTY, SUSPENSION OR TERMINATION OF ONE’S PROFESSIONAL LICENSE.

STATE REGULATION ON MEDICAL RECORDS

The following is a description of the State of Connecticut’s regulations on medical records as it pertains to licensed medical professionals including Licensed Clinical Social Workers.

MEDICAL RECORDS, DEFINITION AND PURPOSE: The purpose of a medical record is to provide a vehicle for: documenting actions taken in patient management; documenting patient progress; providing meaningful medical information to other practitioners should the patient transfer to a new provider or should the provider be unavailable for some reason (patient consent to release information is required in most circumstances – see the confidentiality of social work records information on this web site).

A medical record shall include, but not be limited to, treatment plans, information sufficient to justify any diagnosis and treatment rendered, dates of treatment, referrals to other services, and actions taken by non-licensed persons when ordered or authorized by the provider.

All entries must be signed and dated by the person responsible for them. Licensed Clinical Social Workers should include their license designation of “LCSW” after their name.

REQUIREMENT TO MAINTAIN RECORDS: All Licensed Clinical Social Workers MUST maintain client records. The Department of Public Health can and has taken regulatory action against LCSW’s for not keeping medical records.

RETENTION SCHEDULE: Unless otherwise specified, all parts of a medical record must be retained for a period of seven (7) years from the last date of treatment, or upon the death of the patient, for three (3) years. Nothing in the regulations prevents a practitioner from retaining records longer than the prescribed minimum.

When medical records for a patient are retained by a health care facility or agency, the individual practitioner is not required to maintain duplicate records.

If a claim of malpractice, unprofessional conduct, or negligence with respect to a particular patient is made, or if litigation has been commenced, than all records for that patient must be retained until the matter is resolved.

A consulting health care provider need not retain records if they are sent to the referring provider, who must retain them.

If a patient requests her/his records to be transferred to another provider who then becomes the primary provider to the patient, then the first provider is no longer required to retain the patient’s records.

DISCONTINUANCE OF PRACTICE: Upon the retirement or death of the practitioner, it is the responsibility of the practitioner or responsible relative or executor to inform patients. This must be done by placing a notice in a daily local newspaper published in the community, which is the prime locus of the practice. This notice shall be no less than two columns wide and no less than two inches in height. The notice shall appear twice, seven days apart. In addition, an individual letter is to be sent to each patient seen within the three years preceding the date of discontinuance of the practice.

Medical records must be retained for at least sixty (60) days following both the public and private notice to patients as described above.

A NOTE ON HIPPA

Under HIPPA psychotherapy notes may be held confidential and private and do not have to be disclosed. However to claim confidentiality of psychotherapy notes they must be kept in a separate location from the remainder of the client record and should be in a locked file. Any notes in the main client record are protected under the Confidentiality Statute for social workers in Connecticut, which does allow for release of records in certain circumstances, including a client’s request or mandated reporting.

NASW has detailed information on HIPPA compliance including record keeping. For HIPPA information go to www.socialworkers.org/hippa for the NASW Main HIPPA web page.

ADDITIONAL INFORMATION ON RECORD KEEPING 

In addition to the State Regulations there are other sources of guidance available to social workers in regards to keeping client records, including publications of the NASW Press and information on the national NASW web site, www.socialworkers.org. One excellent source is the NASW Code of Ethics. The following are those sections of the Code that specifically speak to client records:

1.07 Privacy and Confidentiality

(l) Social workers should protect the confidentiality of clients’ written and electronic records and other sensitive information. Social workers should takereasonable steps to ensure that clients’ records are stored in a secure location and that clients’ records are not available to others who are not authorized to have access.

(n) Social workers should transfer or dispose of clients’ records in a manner that protects clients’ confidentiality and is consistent with state statutes governing records and social work licensure.

1.08 Access to Records:

(a)   Social workers should provide clients with reasonable access to records concerning clients. Social workers who are concerned that clients’ access to their records could cause serious misunderstanding or harm to the client should provide assistance in interpreting the records and consultation with the client regarding the records. Social workers should limit clients’ access to their records, or portions of their records, only in exceptional circumstances when there is compelling evidence that such access would cause serious harm to the client. Both clients’ requests and the rationale for withholding some or all of the record should be documented in clients’ files.

(b)  When providing clients with access to their records, social workers should take steps to protect the confidentiality of other individuals identified or discussed in such records.

 

3.04 Client Records:

(a)   Social workers should take reasonable steps to ensure that documentation in  records is accurate and reflects the services provided.

(b)  Social workers should 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.

(c)   Social workers’ documentation should protect clients’ privacy to the extent that is possible and appropriate and should include only information that is directly relevant to the delivery of services.

(d)  Social workers should store records following the termination of services to ensure reasonable future access. Records should be maintained for the number of years required by state statutes or relevant contracts.

Prudent Practice: A Guide For Managing Malpractice Risk, published by NASW Press, 1996, 332 pages, $45.95, is an excellent guide to practice standards including record keeping and includes a CD that has printable forms. This book, that can be purchased through the NASW Press,  www.naswpress.org or 1-800-227-3590, lists the following suggested items to be included in a client record, keeping malpractice risk management in mind:

  • identifying information, including the client’s name, address, telephone number, age, sex, ethnicity, and significant others
  • professional assessment of the client, including diagnosis as appropriate
  • dates of client’s visits
  • the client’s treatment plan, including objectives or goals, and the relationship of the plan to assessment and diagnosis
  • the practitioners treatment modality
  • treatment interventions, including the rationale for selection of interventions in lieu of other alternatives
  • treatment outcome
  • referrals and collaborations
  • fee information, including charges and payments
  • closing note and letter to the client documenting reasons for termination

In addition, the records should include copies of

  • working agreements and service plan
  • fee arrangements
  • signed informed consent and release information forms
  • risks and benefits expected from service
  • prognosis with and without service
  • client contact log and progress notes, including the substance of each session, new problems and needs that develop, interventions, referrals, and recommendations
  • collateral contact log
  • consultations and notes from supervision
  • follow-up notations
  • copies of all correspondence sent and received
  • court documentations.

We also recommend a Law Note from NASW, “Social Workers And Clinical Notes”, November 2001. Ninth in a series of law notes, this note includes 50 pages of text and research citations, as well as four appendices. For order information contact NASW Legal Defense Service, 750 First Street, NE, Suite 700, Washington, D.C., 20002-4241 or call 1-800-638-9799. You may also access information on all the NASW Legal Defense Fund law notes by going to www.socialworkers.org and clicking on Legal Defense Fund and then Law Notes.

The above information is to be used as a guide to record keeping and is not legal advice. State regulations and practice standards are subject to change, as does agency practices that employees need to adhere too.