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Unread July 18th, 2009, 10:52 AM
sk8rgrl23 sk8rgrl23 is offline
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Join Date: Dec 2005
Posts: 53
Default Re: Record keeping dilemma

Quote:
Originally Posted by William Reid View Post
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.
I'm all for categorization.

How bout Puter Tech's suggestion? I think I was thinking more of a cd-rom type program though you're still right about the obsolescence factor. Do you have any suggestions on how to make a sublet office set up work? At this point I"m up to my neck in household expenses per paycheck, and can't see being able to afford to lease an office for quite a while yet. I imagine starting a practice takes about a year or so to even begin to build.

Last edited by sk8rgrl23; July 18th, 2009 at 10:53 AM. Reason: typo
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