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Oregon Bulletin

December 1, 2012

Board of Licensed Professional Counselors and Therapists, Chapter 833

Rule Caption: Client Records/Custodian of Records.

Adm. Order No.: BLPCT 4-2012

Filed with Sec. of State: 10-24-2012

Certified to be Effective: 11-1-12

Notice Publication Date: 6-1-2012

Rules Adopted: 833-020-0501

Rules Amended: 833-010-0001, 833-020-0401, 833-100-0051

Subject: Adds definition of “client records”. Adds content requirements for client records. Adds requirement for designating “custodian of records”. Revises code of ethics to eliminate inconsistent definition of “client records”.

Rules Coordinator: Becky Eklund—(503) 378-5499, ext. 3

833-010-0001

Definitions

The definitions of terms used in ORS 675.705 to 675.835 and these administrative rules of the Board are:

(1) “Accredited college or university” means the college or university is a fully accredited member of one of the regional institutional accreditation bodies.

(2) “Accredited program” means the graduate program is fully accredited by COAMFTE, CACREP, or CORE.

(3) “Board approved program” means a graduate program that the Board has found to be comparable to an accredited program.

(4) “CACREP” means the Council for Accreditation of Counseling and Related Educational Programs.

(5) “Client record” means any information maintained in a written or electronic form about a client.

(6) “Clinical experience” means the professional practice of applying principles and methods to provide assessment, diagnosis, and treatment of individuals and families with mental health disorders.

(7) “COAMFTE” means the Commission on Accreditation of Marriage and Family Therapy Education.

(8) “CORE” means the Council on Rehabilitation Education.

(9) “Direct client contact hours” means only those clinical experience hours that are therapeutic or a combination of assessment and subsequent therapeutic interactions.

(10) “Distance learning” means coursework, or training that does not involve attending a presentation or program in the presence of the instructor or facilitator and other courses through electronic communication.

(11) “Distance Services” means any use of technology that replaces face to face delivery of counseling or therapy service. Such technologies include, but are not limited to, use of computer hardware and software, telephones, the internet, online assessment instruments and other communication devices.

(12) “Electronic communication” means communication through use of videoconference, telephone, teleconference, internet, electronic mail, chat-based, or video-based.

(13) “Equivalent” means comparable in content and quality, but not identical.

(14) “Intern registration plan” means a written description of post-graduate supervised work experience activities an applicant must complete to qualify for a license as a professional counselor or marriage and family therapist.

(15) “Official transcript” means a document certified by an accredited college or university indicating degree earned, hours and types of coursework, examinations and scores, completed by the student; and submitted by the school to the Board.

(16) “Practicing” means engaging in any of the activities listed in the definitions of marriage and family therapy and professional counseling set forth in ORS 675.705, including but not limited to providing clinical supervision to another mental health professional who is providing counseling or therapeutic services to clients.

(17) “Receipt” means the date received by the Board office as shown by US Postal Service postmark, or date received stamp if document was not mailed or without postmark.

(18) “Registered intern” means an applicant for licensure who has met the educational requirement for licensure, and is in the process of obtaining the required supervised work experience under a registration plan approved by the Board.

(19) “Hour Equivalents” means that when requirements for licensure are given in quarter hours, the following formula will be used to determine equivalent hours:

(a) Two semester hours is equal to three quarter hours;

(b) One semester is equal to 1.5 quarters;

(c) One quarter credit hour equals 10 clock hours;

(d) One semester credit hour equals 15 clock hours.

(20) “Supervision” means a professional relationship between a qualified supervisor and an intern, counselor, or therapist during which the supervisor provides guidance and professional skill development and oversight to the intern, counselor or therapist.

Stat. Auth.: ORS 675.715 & 675.785
Stats. Implemented: ORS 675.785
Hist.: LPCT 1-1990(Temp), f. & cert. ef. 3-6-90; LPCT 2-1990, f. 8-31-90, cert. ef. 9-1-90; LPCT 2-1992, f. 11-30-92, cert. ef. 12-1-92; LPCT 1-1993, f. 12-30-93, cert. ef. 1-1-94; LPCT 1-1998, f. 1-2-98, cert. ef. 1-5-98; BLPCT 1-2010, f. & cert. ef. 1-5-10; BLPCT 3-2010, f. 4-30-10, cert. ef. 5-3-10; BLPCT 4-2012, f. 10-24-12, cert. ef. 11-1-12

833-020-0401

Client Records

(1) A licensed professional counselor and licensed marriage family therapist or registered intern must:

(a) Maintain client records for each client;

(b) Ensure that client records are legible;

(c) Keep records in a secure, safe, and retrievable condition; and

(d) Notify the Board if client records have been destroyed or lost.

(2) At a minimum, client records should be recorded concurrently with the services provided and must include:

(a) A formal or informal assessment of the client;

(b) Counseling goals or objectives; and

(c) Progress notes of therapy or counseling sessions.

(3) A licensee must retain client records for at least seven years from the date of the last session with the client.

Stat. Auth.: ORS 675.705 - 675.835
Stats. Implemented: ORS 675.705 - 675.835
Hist.: BLPCT 2-2012, f. 9-5-12, cert. ef. 10-1-12; BLPCT 4-2012, f. 10-24-12, cert. ef. 11-1-12

833-020-0501

Custodian of Record

(1) A licensee or registered intern must:

(a) Arrange for the maintenance of and access to client records that ensure the client’s right to confidentiality and access to records in the event of the death or incapacity of the licensee;

(b) Register with the board the name and contact information of a custodian of record that will have case files and can make necessary referrals if licensee becomes incapacitated or dies; and

(c) Notify the board of changes of the custodian of record.

(2) If the licensee or registered intern is an employee of an organization, the organization may be named as the custodian of record.

(3) The board will not release the name of the custodian of record except in the following cases:

(a) The death or incapacity of the licensee; or

(b) When a client is unable to locate the licensee.

(4) A custodian of record under this rule must be a licensed mental health professional licensed under Oregon law, a licensed medical professional, a health care or mental health organization, an attorney, a school, or a medical records company.

Stat. Auth.: ORS 675.705 - 675.835
Stats. Implemented: ORS 675.705 - 675.835
Hist.: BLPCT 4-2012, f. 10-24-12, cert. ef. 11-1-12

833-100-0051

Confidentiality

(1) A licensee holds in confidence all information obtained in the course of professional services, as within the limits of the setting, such as a public agency. A licensee safeguards client confidences as permitted by rule or law.

(2) A licensee does not use any confidence of a client to the client’s disadvantage.

(3) A licensee, including employees and professional associates of the licensee, does not disclose any confidential information that the licensee, employee, or associate may have acquired in rendering services except as provided by rule or law. All other confidential information is disclosed only with the written informed consent of the client.

(4) A licensee is responsible for being aware of the state and federal regulations concerning confidentiality and for informing clients of the limits of confidentiality as a part of informed consent for services in the context of couple, family, or group treatment. A licensee does not reveal any individual’s confidences to others in the client unit without the prior written permission of that individual.

(5) Whenever a licensee provides services to groups of clients such as couples, families or therapy groups, special care must be taken related to issues of confidentiality. In group therapy, confidentiality issues are to be discussed in the beginning of the group. The parameters of confidentiality within marriage and family therapy are to be discussed early in the counseling process and a clear understanding achieved with all involved.

(6) Whenever a licensee’s services are requested or paid for by one client for another, the licensee informs both clients of the licensee’s responsibility to treat any information gained in the course of rendering the services as confidential information.

(7) A licensee limits access to client records and informs every individual associated with the agency or facility of the licensee, such as a staff member, student, or volunteer, that access to client records must be limited to only the licensee with whom the client has a professional relationship, an individual associated with the agency or facility whose duties require access, and an individual authorized to have access by the written informed written consent of the client.

(8) A licensee maintains the records of a client after the professional relationship between the licensee and the client has ceased and informs clients as to how long records are retained. The licensee stores and disposes of records in ways that maintain confidentiality. The licensee makes advance provision for the confidential disposition of records in the event the licensee is unable to do so for reasons such as illness or death.

(9) A licensee discloses to the Board and its agents any client records that the Board and its agents consider germane to a disciplinary proceeding. The general requirement that licensees keep information confidential does not apply when:

(a) Disclosure is required to prevent clear and imminent danger to the client or others; or

(b) Legal requirements demand that confidential information must be revealed.

(10) A licensee must obtain written informed consent from each client before electronically recording sessions with that client or before permitting third party observations of their sessions.

(11) A licensee adequately disguises the identity of a client when using material derived from a counseling relationship for purposes of training, research, professional meetings, or publications.

(12) A licensee provides clients reasonable access to records concerning them and should take due care to protect the confidences of others contained in those records, or when information from others about the client could result in harm to that person or persons upon disclosure to the client. Following guidelines set forth in ORS 192.518(2) and 675.765(1), unless otherwise ordered by the court, parents shall have access to the client records of juveniles who are receiving professional services from the licensee.

(13) When a licensee is unclear on professional issues or standards of practice, consultation is to be obtained while protecting any confidentiality issue that may be involved.

(14) Licensees proceed cautiously when asked to provide services to a client currently seeing another professional. Consideration is given to the client’s welfare and the situation. Care is given to minimize the risk of confusion and conflict; and when appropriate, the other service provider is consulted. It is not ethical to provide the same therapeutic service that is simultaneously being provided by another professional without collaboration regarding the best interests of the client.

Stat. Auth.: ORS 675.785 - 675.835 & 676.160 - 676.180
Stats. Implemented: ORS 675.785 - 675.835
Hist.: BLPCT 1-2010, f. & cert. ef. 1-5-10; BLPCT 4-2012, f. 10-24-12, cert. ef. 11-1-12

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2011.

2.) Copyright 2012 Oregon Secretary of State: Terms and Conditions of Use

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

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