YOUR PROFESSIONAL RESPONSIBILITY
IS AN ARTICLE WRITTEN BY DR FENNY BRAIDE FOR CAREER DEVELOPMENT TRAINING 2011
No matter the type of clinical practice a mental health care professional enjoys, the odds are almost certain that one of your clients will be involved in litigation. Frequently, during the course of discovery in a legal proceeding, a patient’s mental health becomes an issue. Most often, the attorneys involved in that case will serve a subpoena on a mental health professional to produce records, give a deposition or come to trial and testify.
The question is: should you respond to that subpoena and turn over all your clinical records or give a deposition? The answer is usually NO. A professional in this field must know the policies and guidelines of HIPPA laws and confidentiality. I say to my staff NOT to take progress notes to court proceedings, except exclusively requested or subpoenaed, even that, the situation can only be reviewed and approved by the management team. So far, I have no problem with that policy!
Document u need to testify in a litigation are: (i) CBE part A & and or part B (or psychological evaluation) and or (ii) medication/medical records (no progress notes pls). In MH tx, the progress note defines services provided each week or month u continually see your client/patient, which will include the patients' status or behavior, progression and regression towards goal(s), responds towards your interventions, as well as your impression or interpretation of data / plan. All carries maximum confidentiality between u and the client.
However, on the flip side, clients applying for disability benefits, housing programs, etc, may request that you disclose their demographic/health info to lawyers, doctors, advocates/social workers, and family members; hence creating a problem and conflict with the HIPPA laws. I have actually seen a situation where a client loose his disability case because of what was documented on his progress note. CONFIDENTIALITY MATTERS !
Remember, it is your professional responsibility to obtain a signed 'Release of Info' before you disclose any clinical record to third party.
For staff and career development Training only
Dr. Fenny Braide, is Consultant and psychotherapist
Former IFSI Clinical Administrator and IBHC Lead Clinician in Philadelphia, Pennsylvania
Posted: February 3, 2011
