Professional Practices: Referral & Documentation. Melody Kipp, PhD, LMHC Life & Work Soul utions, Inc. Referral & Documentation. Florida Certification Board, 2004
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Exchange relevant information with the agency or professional to whomthe referral is being made in a manner consistent with confidentiality regulations and generally accepted professional standards of care.
491.0148 Records.--Each psychotherapist who provides services as defined in this chapter shall maintain records. The board may adopt rules defining the minimum requirements for records and reports, including content, length of time records shall be maintained, and transfer of either the records or a report of such records to a subsequent treating practitioner or other individual with written consent of the client or clients.
Counselors are responsible for securing the safety and confidentiality of any counseling records they create, maintain, transfer, or destroy whether the records are written, taped, computerized, or stored in any other medium.
Counselors recognize that counseling records are kept for the benefit of clients, and therefore provide access to records and copies of records when requested by competent clients, unless the records contain information that may be misleading and detrimental to the client. In situations involving multiple clients, access to records is limited to those parts of records that do not include confidential information related to another client.
Counselors obtain written permission from clients to disclose or transfer records to legitimate third parties unless exceptions to confidentiality exist as listed in Section B.1. Steps are taken to ensure that receivers of counseling records are sensitive to their confidential nature.
Psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to:
Subjective (S). The subjective section should include information given or statements made by the patient or the patient family in relation to the current deficits or ability to participate in evaluation or treatment sessions.
Objective (O): Information included in the objective section pertains to exam results, performance on therapy task, and observations made by the clinician.
Assessment (A): This section of the SOAP note contains the problem list and the clinician’s summary of the session, including the patient’s performance and short-term and long-term goals. The clinician generally makes comments on progress in this section. If there are other variable that influence the session, those may be noted in this section as well, such as a suggestion that the patient appears to be a good rehab candidate.
Plan (P): this section contains recommendations and treatment approaches. Treatment plan information may include type of therapy, frequency of therapy, need for further assessment, and plans for discharge