49 Pa. Code § 48.78 - Recordkeeping
(a) For each
client/patient, a licensee shall keep records of the dates of marriage and
family therapy services, types of marriage and family therapy services, details
of the services provided, termination of the professional relationship and
billing information.
(b) Records
kept by the licensee shall be retained for at least 5 years from the date of
the last entry. Records held or owned by government agencies or educational
institutions are not subject to this requirement.
(c) Licensees shall take reasonable steps to
ensure that documentation in records is accurate, legible and reflects the
services provided.
(d) Licensees
shall include sufficient and timely documentation in records to facilitate the
delivery of services and to ensure continuity of services provided to the
client/patient in the future.
(e)
Licensees' documentation shall protect clients'/patients' privacy to the extent
that it is consistent with applicable Federal and State laws and regulations
and should include information that is directly relevant to the delivery of
services.
(f) Licensees shall store
records following termination of services to ensure reasonable future access.
Records shall be retained and stored as required by applicable Federal and
State law and regulations.
(g)
Licensees shall provide a client/patient with reasonable access to records
concerning the client/patient. Licensees who are concerned that
clients'/patients' access to their records could cause serious harm to the
client/patient or another person shall provide assistance in interpreting the
records and consultation with the client/patient regarding the records.
Licensees shall limit clients'/patients' access to their records, or portions
of their records, only in exceptional circumstances when there is compelling
evidence that the access would cause serious harm to the client/patient or
another person. Both the clients'/patients' requests and the rationale for
withholding some or all of the records shall be documented in the
clients'/patients' files. When providing clients/patients with access to their
records, licensees shall take steps to protect the confidentiality of other
individuals identified or discussed in such records.
(h) In the event of the licensee moving from
the area or closing the licensee's practice, a licensee shall arrange for the
storage, transfer or disposal of client/patient records in ways that maintain
confidentiality and safeguard the welfare of clients/patients.
Notes
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