The fact is, in most states you have both the right to ask and to have copies made and make an addendum if you do not agree with what you see.
My position on the mental health record is based on the prevailing laws and professional standards (most of which allow and even encourage consumer access) and also a maxim called Riolo’s Rule. If something has my name on it or is about me, it may be private. However it is never private from me. The paper or computer it is on may belong to others but the information is mine. There are no exceptions. None.
If you had your record in your hands, what kinds of information are you most likely to see? It’s difficult to say. As embarrassing as it is for me to say, the variability in record keeping among psychotherapists is astounding. Some therapists keep little to no records while others have detailed minutia about you. Both extremes are potentially dangerous. Too little is a violation of professional standards. What if someone else had to step into to help in an emergency? Too much and you can have your privacy compromised if that information were to get in the wrong hands. But what is just right?
If you recall in the last article on Victories, I mentioned the Oxford Health Plan audits. Although Oxford agreed to halt the audits and stop demanding that fees be returned, there was an admission that record keeping was less than adequate and variable which is another way of saying there was poor quality control.
The argument that providers used with Oxford Health Plan was that there was no set standard for record keeping, therefore the providers who were audited should not be held accountable. While there may not be one particular model or standard it is not been my experience that there have been none at all. Not only managed care organizations but also professional organizations, educators and scholars have put out guidelines for outpatient mental health records. I am not that surprised that many clinicians especially in private practice, fail to incorporate them but I am a bit surprised to hear them say they do not exist.
Let’s take a look at what some of the most common recommendations are and examine their pluses and minuses for the consumer.
There are some professionals who make a decision not to keep records or to keep records anonymous on the grounds of safeguarding your privacy. This is not an option if insurance is involved or if the patient has serious mental health problems. Most licensing boards mandate that all health professionals keep records and those who do not do so put themselves at considerable risk.
How long should records be kept? Some states have minimum periods. It may vary from state to state. However, The American Professional Agency, the NASW liability insurance carrier for social workers, for example, recommends indefinitely as a risk management practice. One never knows when a patient may raise some issue about the treatment and the record, depending on what is in it, could be invaluable to either side.
While basic demographics information is essential there is reasonable variance of opinion in terms of the required detail. Some will include only basic information while others might include items such are living arrangements, employer etc. In some cases the information may be pertinent, and in others, less so.
For example, suppose you are homosexual and the problem you have is not related in any reasonable way to your sexual orientation. Do you want your therapist to include that in your record with the possibility that it can get into the hands of others? Some therapists will insist in its inclusion while others might be more flexible.
What should be clear is that the record is explicit on whom it pertains to and that there is little to no chance of confusing one patient with another. For instance, if two patients have the same name, it should be clear that John Smith Sr. is not confused with John Smith Jr.
Records should also reflect that your therapist informed you about issues such as confidentiality and it’s limitations, his or her fees, payment arrangements, and cancellations policy and collection methods.
Permissions
There may be any number of circumstances where it is useful or important for your therapist to share information with another party about your treatment. Permissions should be in writing and reflect who will have access to your records and under what circumstances
Permission to communicate with your primary care physician requires special mention. Some therapists and most managed care organizations will argue that this is essential. Some therapists rarely make an attempt to communicate with your primary care physician (PCP). Others take the position that it depends on the circumstances. It you have medical problems that are related in some way to the reason you sought therapy it would be unwise for your therapist not to coordinate with you physicians. If you have a mental health condition that has a biological component and your therapist is not a physician it is also extremely important. Remember psychotherapists who are not physicians may be very good therapists but we cannot practice medicine. We are not trained for that nor are we licensed to do so. It is important to stay within our level of competence. Referral information is also crucial and can be useful. Who recommended you and why?
History and description of the presenting problem(s)
Now we are getting to the heart of the matter. Why are you seeking therapy? What problem or issue do you need help to resolve? It can be many things. How long the condition has persisted and what you have done in the past to deal with the problem(s) can be critical.
Mental status evaluation and risk potential
Many people who see a therapist for the first time are somewhat taken aback by some of the questions a therapist might ask. Are you suicidal? Do you hear voices? How much do you drink or use drugs etc. You say, but really, why does the therapist have to ask I did not give any indication I was in really bad shape did I? However, a wise therapist asks just to be sure. Better to ask a stupid question than to fail to ask a really important one.
Progress
Some therapists forget this part. They will take all kind of notes. They will write about your dreams, your transference, and your resistance and your fantasies. However if you look at the record there would be no way to know if you are getting better, remaining the same or getting worse. How do they know?
Progress notes should reflect what changes are occurring in the course of your treatment. And, if the change is not sufficient or fast enough it should reflect what modifications in your treatment might be necessary to get the desired results. Periodically this may be summarized in the form of a “treatment plan”.
Lastly, there should be some kind of “end game”. How will your therapist know when it’s time to end or at least halt therapy? This may be listed in the form of goals that are measurable by some method. It does not have to be by some rigid formula, but it should be reasonably clear when it is time to stop.
So as you can see your treatment record can contain a great deal of information about you. Used properly by a good user-friendly therapist it can be invaluable. If this information gets in the wrong hands it can embarrass you or cause you problems.
In the next article we will discuss who besides you may get to see all or parts of your record.