Ohio Admin. Code 4757-5-09 - Standards of ethical practice and professional conduct: record keeping

(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 services, 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.

(F)(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.

(G)(L) A licensee or registrant shall not condone, partake, or assist in billing irregularities with respect to insurance companies or direct billing.

(H)(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.

(I)(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.

Notes

Ohio Admin. Code 4757-5-09

Effective: 7/1/2024
Five Year Review (FYR) Dates: 12/26/2028
Promulgated Under: 119.03
Statutory Authority: 4757.11
Rule Amplifies: 4757.11
Prior Effective Dates: 06/11/1985 (Emer.), 09/19/1985 (Emer.), 12/19/1985, 05/22/1986, 07/03/1997, 08/02/2001, 09/20/2002, 04/10/2004, 01/01/2006, 11/08/2007, 11/02/2008, 10/18/2009, 04/01/2011, 09/03/2018, 12/26/2023