Releasing records is an intimidating issue for many counselors and therapists. And while we hear a lot of rhetoric on the topic, many counselors are not clear on legal and ethical expectations and end up making poor judgment calls because of that.
A common scenario is that a client requests their records and a counselor automatically refuses to release the records, stating confidentiality concerns. While these concerns are valid, that is not following the law within the United States. Clients do have the right to access their records. From their physician. From their physical therapist. From their mental health therapist.
There are some exceptions and those differ slightly among state law; however, those exceptions are typically in more extreme cases and require the therapist to prove that access to the records would cause significant harm. Furthermore, these laws still often allow access of the records to someone the client designates.
Does this mean that therapists then release records automatically any time a client makes such a request? Not necessarily.
The most common practice is first to talk with your client about the purpose for the release. Determine what it is they are hoping to gain from releasing or accessing their records. Oftentimes, this discussion will help the client identify that they actually would prefer a treatment summary from the counselor.
During this discussion with your client it is important to highlight anything that could potentially be misconstrued or misinterpreted if released. However, there are many times when the client still requests the records and the therapist is required to release them. This can be an unsettling discussion for many therapists and that's why I encourage you to consider these scenarios ahead of time, before any complicated situation arises.
I have some strategies you can use to make releasing your records (if necessary) a much less stressful experience:
Think about your client viewing their notes
When writing notes, treatment plans and assessments, work under the assumption that your client will one day view these. This practice helps you to keep language more objective, strengths-based and to the point.
This does not mean you hide important details or only write the positive things about your client. Keep things honest and real. Your ethics require you to document what actually happened as well as your professional assessment of the client's situation. However, there are often minor tweaks that therapists will make when considering their client actually reading the note and this will improve the objectivity and clarity of your notes.
Think about and discuss your policies
It is important to make sure your policies for releasing records are outlined in your informed consent document... and that you review this with your clients at the outset.
I do not recommend saying in your policy that you will NOT release records because this is not a practice you can legally uphold, except in special circumstances. Instead, note that you will discuss with your client the reasons for the request and make recommendations accordingly. This encourages collaboration should your client make a request at some time later on.
Also, you can choose to charge for things like making copies, time spent writing a treatment summary or time consulting with other professionals on behalf of the client (such as their attorney). However, if you don't have these charges outlined in your Services Agreement then you may end up spending money and time without reasonable reimbursement.
In my paperwork packet available for purchase, I make sure to include these things, along with a more in-depth court policy provided by Nicol Stolar-Peterson, LCSW BCD from www.therapistcourtprep.com. If you already have a paperwork packet but are looking for a court policy to add on, you can purchase that on her website for a very reasonable $37.
Have the insurance conversation
Lastly, if you have clients who are being reimbursed by their insurance company or if you contract with their insurance company, make sure they are aware that all records can be accessed by the insurance company. Like it or not, by allowing a third party to pay for services, clients are also allowing a third party to check up on those services.
That also means that you need to consider how that relates to your records. For example, many therapists will downplay client symptoms in an attempt to avoid stigmatizing their clients. However, to an insurance company that makes it seem as though your client doesn't need the services you're providing. FYI, it's also considered fraud to either "downgrade" or "upgrade" your client's diagnosis.
That's why a basic, easy to remember rule with documentation is to always keep things honest.
However, if you're looking for help specifically with how insurance and your paperwork connect, you can check out my new on-demand training The Counselor's Guide to Documenting for Insurance (now available as part of the Meaningful Documentation Academy). There are so many things to think about with your work, let's make paperwork as stress-free as possible!
Do you have any other tips on what to consider when preparing your records for release? Any tips from past experience? Feel free to share in the comments below!