Client Access to Medical Records

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Table of Contents

Introduction
Applicable ACA Codes
Applicable State Codes
Conclusion
References

Introduction

A patient decides to terminate her counseling after a couple of weeks and asks the counselor to give her all records and notes that she made during sessions. According to the ACA Code of Ethics and the state board code of ethics, the counselor should grant the client access to her records with the exclusion of psychotherapy notes, provided it is not potentially dangerous to her mental health. Psychotherapy notes are considered sensitive information that is not meant to be used by anyone other than the therapist.

Applicable ACA Codes

The Code of Ethics of the American Counseling Association (ACA) stipulates that clients personal information is confidential. Section B.6.e. states that counselors are entitled to provide access to records when requested by competent clients only limited by the cases when there is compelling evidence that such access would cause harm to the client (American Counseling Association, 2014, p. 8). Counselors are supposed to assist and consult clients in interpreting their records. However, this provision does not apply to the notes kept by a counselor during sessions. According to the ACA Code of Ethics, records are defined as all information or documents, in any medium, that the counselor keeps about the client, excluding personal and psychotherapy notes (American Counseling Association, 2014, p. 20). Thus, a counselor should grant the client access to their records, excluding psychotherapy notes, provided that it would not cause them harm.

Applicable State Codes

On the state level, patient data privacy is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). According to Paragraph 164.524, an individual has a right of access to inspect and obtain a copy of protected health information about the individual in a designated record set (U.S. Department of Health and Human Services, 2013, p. 105). The exceptions that are not part of a designated record set include, among others, psychotherapy notes. They are defined as notes recorded by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint or family counseling session (U.S. Department of Health and Human Services, 2013, p. 76). They are kept separate from the clients medical records and include the therapists impressions about the patient and details of conversations that are intended to help them during therapy.

The information in psychotherapy notes is considered sensitive and is not meant to be used by anyone other than the counselor. It does not include any information that would normally be disclosed for treatment, such as medical prescriptions, results of clinical tests, and any information related to diagnosis, the treatment plan, symptoms, prognosis, and the clients progress (U.S. Department of Health and Human Services, 2013, p. 76). Thus, a client can be granted access to their medical records but not psychotherapy notes that are kept separate from other files.

Conclusion

Both the ACA Code of Ethics and the HIPAA set the same rules regarding clients access to their medical records. Patients have the right to get a copy of their records, and health care professionals are entitled to grant them access, provided it does not threaten the clients mental health. However, psychotherapy notes are not included in the documents available to the client. When a client requests access to all their medical records, it should be explained to them what psychotherapy notes are used for and how they are handled. A counselor should also stress that they are not transferred to another counselor and remain in their possession.

References

American Counseling Association. (2014.) ACA Code of Ethics. Web.

U.S. Department of Health and Human Services. (2013). HIPAA Administrative Simplification. Web.

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Client Access to Medical Records

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