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Law
Note Series
Social
Workers and Clinical Notes
by: Sherri L. Morgan, MSW,
JD and Carolyn Polowy, JD
Published: November 2001 © NASW
Pages: 100, including 4 appendices
INTRODUCTION
[citation omitted]
Introduction: This law note
reviews legal issues specifically germane to social workers' clinical notes
or "psychotherapy notes." However, a discussion of clinical notes takes place
under various categories of guiding principles, including the NASW Code
of Ethics, state medical records acts, social work licensing laws, specific
federal and state psychotherapy privacy protection statutes, and state regulations
applicable to social work case records in general. The definition and even
the existence of clinical notes as distinct from medical or case records
has been a matter of some disagreement among states, while recently issued
federal regulations recognize psychotherapy notes as a distinct part of the
mental health record accorded special privacy protection. This law note reviews
legal opinions, statutory and regulatory language, and ethical principles
that control the creation, handling, protection, and release of clinical
notes within social work practice. It provides guideposts for professional
practice, but does not aim to resolve particular legal problems. Consultation
with an attorney, a social work licensing board representative, and other
mental health professionals is necessary to resolve particular issues related
to clinical notes.
The legal precedent and statutory
support discussed in detail in this law note should cement social workers'
understanding that it is essential to maintain accurate and timely clinical
notes. Clinical notes facilitate the delivery of mental health services,
ensure continuity of care, protect clients' privacy, and ensure reasonable
future access to client treatment history. Contemporaneous clinical notes
are an important part of the client record, as are evaluations, treatment
plans, prognoses, collateral contacts, contact dates, and payment plans.
Clinical notes often contain the most private client information as well
as the therapist's observations, clinical concerns, and relevant anecdotal
information. Social workers sometimes hold the view that the obligation to
keep such records is a discretionary one. Although discretion is required
when determining what to include and how to phrase comments, this law note
provides abundant support for the proposition that clinical notes are necessary
to create an accurate treatment record and demonstrate commitment to professional
practice standards.
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