This month’s free law and ethics practice question will test your knowledge on therapy records. Regardless of where you work, (agency, private practice, county mental health, etc.) therapy records are a must! Therapists must maintain therapy records that meet the standard of care; without them, therapists are vulnerable to legal liability. There are a variety of ways this topic can be tested on your California law and ethics exam.
Here are some common questions:
- How long must records be retained?
- Who has access to client records?
- What should be included in therapy records?
- Who owns therapy records?
- How should therapy records be stored?
Let’s test your knowledge on one aspect of therapy records that could be tested and see how you do!
A new client referred through California Victims of Crime (VOC) meets with a therapist working in a mental health agency. The client has a diagnosis of Acute Stress Disorder. During the first session, the client explains that her ex-partner was stalking her for months, broke into her apartment and physically assaulted her. She shares that she is scared to talk with anyone because her ex is in law enforcement and has a way of “finding stuff out.” She asks the therapist to keep all information private and not maintain records, as she is convinced the ex will gain access to them. How should the therapist respond to address their legal and ethical obligations?
A. Inform the client that you must legally maintain records that meet the standard of care, but assure her only the therapist will have access to them.
B. Inform the client that you must legally maintain records that meet the standard of care and discuss what information will be shared with VOC.
C. Discuss client’s concerns and agree to keep limited information in client records.
D. Discuss what information will be included in therapy record, who may request access, and maintain records that meet the standard of care.
(scroll down for the correct answer)
The correct answer is D.
The question is asking about both ethical and legal responsibilities. Therefore, you want to ensure your answer adequately addresses both legal and ethical concerns.
Answer A is partially correct; the therapist must legally maintain records. However, the second part is incorrect; we cannot guarantee complete confidentiality of records. This is especially true since the client is receiving services through a third party payer, which means records could be audited.
Answer B is incorrect because it provides an incomplete response. It would be important to let the client know what could be shared with VOC. However, VOC is not the only entity who could review records. For example, if the client engages in a lawsuit against the perpetrator of violence, records could be subpoenaed.
The first part of Answer C is good; ethically, it would be important to discuss the client’s concerns. However, the therapist should not limit what is kept in the therapy records based on the client’s concerns. The therapist should include basic components of the record to meet the standard of care, which may or may not align with the client’s wishes.
Answer D is the strongest option available. It addresses the therapist’s ethical responsibility by engaging in a discussion with the client about what information will be recorded and who could potentially access records. It also adequately addresses the therapist’s legal obligation of maintaining records that meet the standard of care.
How did you do on this question? Does the correct answer and rationale align with your understanding of therapy records, or did you learn something new? If you have any additional questions, you are welcome to check in with a TDC coach. Our coaches are here to answer your questions and provide support and guidance as you prepare to PASS your California law and ethics exam with confidence!
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