246-809-010  <<  246-809-035 >>   246-809-040

Recordkeeping and retention.

(1) The licensed counselor or associate providing professional services to a client or providing services billed to a third-party payor, must document services, except as provided in subsection (2) of this section. The documentation includes:
(a) Client name;
(b) The fee arrangement and record of payments;
(c) Dates counseling was received;
(d) Disclosure form, signed by licensed counselor and client or associate and client;
(e) The presenting problem(s), purpose or diagnosis;
(f) Notation and results of formal consults, including information obtained from other persons or agencies through a release of information;
(g) Progress notes sufficient to support responsible clinical practice for the type of theoretical orientation/therapy the licensed counselor or associate uses. The associate must provide adequate information about their clinical work to the approved supervisor. This can be in the form of progress notes, case discussions/analysis, or reports from collaborating professionals. The approved supervisor must have an understanding of the clinical work that the associate is doing.
(2) If a client requests that no treatment records be kept, and the licensed counselor or associate agrees to the request, the request must be in writing and the licensed counselor or associate must retain only the following documentation:
(a) Client name;
(b) Fee arrangement and record of payments;
(c) Dates counseling was received;
(d) Disclosure form, signed by licensed counselor or associate and client;
(e) Written request that no records be kept.
(3) The licensed counselor or associate may not agree to the request if maintaining records is required by other state or federal law.
(4) The licensed counselor or associate or the associate's supervisor must keep all records for a period of five years following the last visit. Within this five-year period, all records must be maintained safely, with properly limited access.
(5) The licensed counselor or associate or the associate's supervisor must make provisions for retaining or transferring records in the event of going out of business, death or incapacitation. These provisions may be made in the practitioner's will, an office policy, or by ensuring another licensed counselor is available to review records with a client and recommend a course of action; or other appropriate means as determined by the licensed counselor or associate.
[Statutory Authority: Chapter 18.225 RCW. WSR 09-15-039, § 246-809-035, filed 7/8/09, effective 7/8/09. Statutory Authority: RCW 18.225.040, 18.130.050. WSR 06-09-032, § 246-809-035, filed 4/12/06, effective 5/13/06.]
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