FREE Practice Question: Record Keeping

This week, we are excited to expand TDC’s professional development opportunities for therapists with the launch of our first continuing education courses. This first set of courses focuses on the laws and ethics of our profession. In honor of these courses, this week’s free MFT practice question will explore the legal issue of record keeping. More specifically, we will examine who has the right to access client records.

When it comes to working with couples, record keeping is more complex than working with individuals. Some therapists try to simplify the process by maintaining separate files for each member of the treatment unit, with one record for partner A and another for partner B. However, this may not be advisable since the client is the couple and all treatment goals and case notes will pertain to the dynamics within the treatment unit. Thus, it would make more sense to keep a single file for the client (the couple) with this file containing information regarding both partners. It is important during the informed consent process to make this policy clear to your clients.

If you maintain a single client file, what happens if one member of the treatment unit wants to access the records? Since the records include information about more than one person, you would need to take steps to ensure confidentiality is being protected adequately for all members of the treatment unit. There are two options available to a therapist in this case. To meet the legal requirements of confidentiality, you would either want to set a policy that requires each member of the treatment unit to sign an authorization of release before sharing records with either party OR you can provide records to one member of the treatment unit with only an authorization of release from that member, but you must then redact (black out) all information related to the other member(s).

With this in mind, let’s take a look at the question.

QUESTION:

A therapist worked with a couple for several years following mutual infidelity. The couple separated after two years in treatment and is in the midst of divorce proceedings. The husband requests access to his records. What actions should the therapist take to address the legal issues presented in this case?

a. Inform the husband that the records belong to both the husband and wife and would require a release of information from both.

b. Request a written release from the husband and turn over all of the records, but redact information deemed detrimental to the wife’s well-being or therapeutic relationship.

c. Determine how access to records would affect the therapeutic relationship and the well being of the husband and wife.

d. Inform the husband that records belong to both the husband and wife and request the wife sign a release.

So, what would we do here? Leave your answer in the comments below and be sure to tune in tomorrow for the answer and a discussion of the rationale!