Who Is Responsible for Client Records?
Do you know who is responsible for your client records? Sure it's obvious in your solo practice that the duty falls to YOU. But, what if you are a 1099 contractor in a big practice? This is especially important for clinical supervisors to know about their supervisees. Listen to Texas Counselors Creating Badass Businesses Episode 27 and discover one way to make sure you know if you are (or your supervisee is) the records custodian at your place of employment.
TCCBB #27 Who is Responsible for Client Records
What is a client record?
A client record generally contains progress notes, intake paperwork, assessments, billing records, and any artifacts generated from client sessions.
Since this information can potentially identify a client, it is called protected health information or PHI. Records can be virtual or physical. PHI belongs to the client and as clinicians we are obligated to protect it. Federal laws like HIPAA, Texas laws like HB 300, and licensure rules dictate how the records are to be maintained, and under what circumstances they can be released.
But who is in charge of following those rules and laws?
What is a records custodian?
Everyone from the therapist to front office staff who comes in contact with PHI is obligated to protect it.
A records custodian, however, is the individual or organization responsible for the management of client records. This may involve creating, maintaining, and storing client records in a secure and confidential manner; destroying them safely and ethically after a certain period of time; and ensuring that the records are accessible to authorized parties when necessary.
In Texas, the LPC rules recently changed and LPC Associates are permitted to manage their own client records.
As a custodian of client records, the individual or organization has legal and ethical obligations to maintain the confidentiality and privacy of the records, and to protect them from unauthorized access, use, or disclosure.
They may also be responsible for responding to requests for access to or copies of client records, and for complying with relevant laws and regulations governing the handling of sensitive client information.
In some cases, being a client records custodian may be a formal role or position within a specific profession, such as healthcare or law. In other cases, it may refer more generally to anyone who is responsible for managing and protecting client records. This includes business owner or manager who maintains customer records.
Are YOU the Records Custodian at Your Job? It's Not Always Clear
Your employment contract (or your supervisee’s employment contract) should have the answer about who the records custodian is.
What is more frustrating than getting a subpoena for client records?
- Finding out your client records were released by the records custodian at your job and you thought that was YOUR responsibility
- Discovering that your supervisee is the records custodian and they haven’t been maintaining them properly
- Discovering YOU are a records custodian and you haven't been maintaining them properly
Get a copy of your contract and verify who the records custodian is at your place of employment.
In a small practice, go a step further and verify that the owners are licensed. If they are not, then ask if they have been properly trained as a records custodian.
Employees and contractors must know who is responsible for client records on the job. Clinical supervisors must know whether or not their supervisees are records custodians. Getting a copy of the contract and taking a look is only the first step to making sure your client's protected health information is actually protected.
Blog post by Kate Walker LPC/LMFT Supervisor in Texas
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