1. (a) For each client/patient, a licensee shall keep records of the dates of professional counseling services, types of professional counseling services, details of the services provided, termination of the professional relationship, and billing information.
2. (b) Records kept by the licensee shall be retained for at least 5 years from the date of the last entry. Records held or owned by government agencies or educational institutions are not subject to this requirement.
3. (c) Licensees shall take reasonable steps to ensure that documentation in records is accurate, legible and reflects the services provided.
4. (d) Licensees shall include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to the client/patient in the future.
5. (e) Licensees’ documentation shall protect clients’/patients’ privacy to the extent that it is consistent with applicable Federal and State laws and regulations and should include information that is directly relevant to the delivery of services.
6. (f) Licensees shall store records following termination of services to ensure reasonable future access. Records shall be retained and stored as required by applicable Federal and State law and regulations.
7. (g) Licensees shall provide a client/patient with reasonable access to records concerning the client/patient. Licensees who are concerned that clients’/patients’ access to their records could cause serious harm to the client/patient or another person shall provide assistance in interpreting the records and consultation with the client/patient regarding the records. Licensees may limit clients’/patients’ access to their records, or portions of their records, only in exceptional circumstances when there is compelling evidence that the access would cause serious harm to the client/patient or another person. Both the clients’/patients’ requests and the rationale for withholding some or all of the records shall be documented in the clients’/patients’ files. When providing clients/patients with access to their records, licensees shall take steps to protect the confidentiality of other individuals identified or discussed in the records.
8. (h) In the event of the licensee moving from the area or closing the licensee’s practice, a licensee shall arrange for the storage, transfer or disposal of client/patient records in ways that maintain confidentiality and safeguard the welfare of clients/patients.

Source

The provisions of this § 49.78 adopted September 17, 2010, effective September 18, 2010, 40 Pa.B. 5320.