HIPPA TERMS & KEY ISSUES; PSYCHOTHERAPY NOTES 2 Correct Ans-• Psychotherapy notes are also
generally not provided to the client if s/he makes a written request for access to records. This is
contrasted with "medical record" or the "psychotherapy record" which are generally accessible by the
client if they make a written request for access to records.
• Not disclosed with a subpoena: Psychotherapy notes would not be included in the disclosure per a
subpoena if a client's records were court-ordered to be released or if privilege was waived by the client
or client's representative in a
1. The right to request restrictions on certain uses and disclosures of their
protected health information
2. The right to receive confidential communications from health care providers.
3. The right to inspect and receive a copy of their PHI.
4. The right to amend their PHI.
5. The right to receive a paper copy of the therapist's Notice of Privacy Practices
(NPP)
o The NPP must be given to clients on or before the first time they receive treatment.
o A copy of the NPP must also be posted on the therapist's premises and/or prominently on the
therapist's website.
o Therapists must receive some form of written acknowledgement from clients that they have received a
copy of the NPP.
o The NPP must:
▪ Be written in plain language.
▪ Contain a prominent statement about how the therapist will use and disclose the client's PHI.
▪ Describe how the therapist protects health information under the Privacy Rule.
,▪ Specify circumstances when health information may be used or disclosed without the patient's consent
or authorization (exceptions to confidentiality).
▪ Describe the uses and disclosures that are allowed for treatment, payment, and health care operation
purposes.
▪ Describe the rights that clients have with respect to their PHI.
▪ Notify clients of how they may obtain access to their PHI.
LEGAL VS. ETHICAL: LEGAL 3 Correct Ans-LEGALLY THERAPISTS MUST:
• Keep clinically sound medical records
• Keep records locked and secure at all times
• Maintain clinical sound medical records for 7 years or until a minor client is 25
• NOT alter medical records
• Obtain signed authorization to release records
• NOT engage in sexual relations with clients or terminate therapy in order to
engage in a sexual relationship with clients
• Provide the BBS brochure "Professional Therapy Never Includes Sex" to any
adult client who reports sex with a previous therapist
• NOT engage in false or misleading advertising
• NOT alter diagnoses or treatment unit in order to get paid
• NOT submit false treatment claims to third party payers
LEGAL VS ETHICAL: LEGAL 2 Correct Ans-• Report suspected child abuse/neglect immediately and file
a report within 36
hours
• Report suspected elder abuse/neglect immediately and file a report within 2
days
• Take "appropriate preventive measures" to avert harm to suicidal clients (Duty
to Protect)
• Assess and document the assessment of a client's potential for committing
violence (Duty to Protect)
, • Notify local law enforcement when a client has made a specific and serious
(i.e. imminent) threat to an identifiable other
• Obtain a signed release to share information/records
• Manage issues of privilege when records are requested in a legal proceeding
• NOT offer or accept payment for referrals
• Comply with HIPAA standards if a covered HIPAA entity
• Consider potential conflicts when treating multiple parties of a treatment unit
• Inform client or treatment unit of any potential consequences of therapist client
role changes
• Document treatment decisions and maintain clinically sound records
• Store, transport, and dispose of records in ways that protect confidentiality
• Advise patients of information that will likely be disclosed to a third party
payer
• Maintain confidentiality expect when mandated or permitted by law
• Obtain signed authorization from every member of treatment unit (old enough
to consent) to release information
• Obtain written consent from a patient to use their clinical information in a presentation
LEGAL VS ETHICAL: ETHICAL 3 Correct Ans-• When in another location, provide local emergency
resources
• Obtain written consent to record a session or permit third party observation
• Inform clients of the limits of confidentiality
• Inform clients of the therapist's professional background
• NOT use professional relationships to further their own interests
• Continue the therapeutic relationship only if it is reasonably clear the client is
benefiting
• NOT withhold records because a client has not paid for services
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