4 CCR 737-1.16 - RECORDS REQUIRED TO BE KEPT AND RECORD RETENTION (C.R.S. sections 12-245-204(4), 12-245-224(1)(u))
A.
General. Every
licensed professional counselor shall create and shall maintain a record as
defined in subsection (B) of this Rule for each client, this record shall be
retained for a period of seven years, commencing on either the termination of
professional counseling services or the date of last contact with the client,
whichever is later. Exception. When the client is a
child, the record shall be retained for a period of seven years commencing
either upon the last day of treatment or when the child reaches eighteen years
of age, whichever comes later, but in no event shall records be kept for more
than twelve years.
B. The record
shall contain, as applicable to the mental health services rendered, the
following information:
1. Name of treating
therapist;
2. Client's identifying
data to include name, address, telephone number, gender, date of birth, and if
applicable the name of the parent or guardian. If the client is an
organization, the name of the organization, telephone number and name of the
principal authorizing the mental health provider's services or
treatment;
3. Reason(s) for the
psychotherapy services;
4.
Mandatory disclosure statement(s);
5. Dates of service including, but not
limited to the date of each contact with client, the date on which services
began, and the date of last contact with client;
6. Types of service;
7. Fees;
8. Any release of information;
9. The record shall justify and describe the
assessment, diagnosis and therapy/treatment administered in a legible document.
The records must be prepared in a manner that allows any subsequent provider to
yield a comprehensive conclusion as to what occurred;
10. Name of any test administered, each date
on which the test was administered, and the name(s) of the person(s)
administering the test;
11. A final
closing statement (if services are over).
C.
Record Storage.
Every professional counselor shall keep and store client records in a secure
place and in a manner that both assures that only authorized persons have
access to the records and protects the confidentiality of the records and of
the information contained of the records.
D.
Transfer of
Records. Whenever a professional counselor deems it necessary to
transfer her/his records to another professional counselor or other health care
provider, the professional counselor making the transfer shall obtain the
client's consent to transfer (when possible).
E.
Disposition of
Records. If the professional counselor is not available to handle
her/his own records, the professional counselor and /or his estate shall
designate an appropriate person to handle the disposition of records. A plan
for the disposition of records shall be in place for all professional
counselors for the following conditions:
1.
Disability, illness or death of the professional counselor.
2. Termination of the professional
counselor's practice.
3. Sale or
transfer of a practice.
F.
Record
destruction. Every professional counselor shall dispose of client
records in a manner or by a process that destroys or obliterates all client
identifying data. However, records cannot be destroyed until after seven years
or as otherwise provided in these rules or any other applicable statutes or
rules.
G.
Record
Keeping in agency/institutional setting. A professional counselor
need not create and maintain client records if the professional counselor
practices in an agency or institution and if the professional counselor:
1. Sees the client in the usual course of
that practice;
2. Keeps client
records as required by the agency or institution, and;
3. The agency or institution maintains client
records.
Notes
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