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Unread July 6th, 2009, 09:56 AM
William Reid William Reid is offline
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Join Date: Jul 2004
Location: Texas
Posts: 105
Default Re: Record keeping dilemma

In my view (I'm not a records librarian), clinical records must be (1) safeguarded from unauthorized readers, (2) reasonably available for your review and sharing with authorized persons, (3) reasonably protected from destruction or loss, and (4) kept for a really long time. There may be a minimum time period in your state, but I'd double it.

I would not keep records online. I know that's dark-ages thinking, but (a) there are (a) real confidentiality issues; (b) possible access issues (no Web access sometimes? forgot the password?); (c) possible future format/compatibility issues (I used to write papers in WordStar on a CP/M platform), and, perhaps most important, (d) real probabilities that the website that keeps them will go out of business within a few years. (How many Web companies that existed in 2004 don't exist today, especially small ones?)

I seem to be categorizing things today, (i) because it's early in the day and (ii) because it provides the illusion that I know what I'm doing.

Education vs. group counseling/therapy? I'll leave that to someone else.

Meantime, it might be wise to remember the purposes of clinical records, when thinking about how to create and store them: (#) to document what you've done, (%) to help you remember what's going on with the patient/client as you treat him/her over time (or after a long absence), and (*) to communicate to other treaters -- current and well into the future -- things they need to know as they work with the person. Good documentation can be important for years to come, in clinical, administrative, and forensic settings. Don't skimp: you are far more likely to get into trouble for too-skimpy documentation than for too much, and clarifying details are far more likely to help you (and your patient/client) than to hurt you.
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