Preserving Your Records

Record Keeping Tips

Maintaining your records becomes your primary risk management technique. Records can be a nuisance but as your career progresses, they may become more unwieldy and you may be tempted to dispose of them. A word to the wise, DON’T.

Maintain a secure chain of custody.

Always know where your records are and who is responsible for securing them. Remember that you are responsible for producing your records if you are subpoenaed, and failure to do so reflects poorly on you in social work malpractice litigation.

Make sure your records are in good order and follow the sequence of treatment.

The plaintiff’s attorney will be analyzing your records to ascertain if you deviated from the standard of care.

Make sure your records are legible and cogent.

The tendency for cryptic and erratic shorthand is too easily left open to interpretation.

Make sure that your records are in a safe place.

While it is unreasonable to expect you to protect your records from all types of natural disaster, fireproof file cabinets are recommended. With the additional responsibilities imposed by The Health Insurance Portability and Accountability Act of 1996 (HIPAA), security is now codified.

For hard copy files, there must be at least two locks that protect the record and access to the records must be restricted. For digital files, there must be at least two security features protecting the data—for example, a password-protected laptop that is also locked in a cabinet.

Never change your records without acknowledging it.

Obviously, there are times when you change your diagnosis and/or treatment plan as therapy progresses, however, these changes should be separate entries in your records. If it is necessary to go back and make a correction or addition, clearly indicate you are making an addendum, date it, and sign it.

Investigate various types of secure media to preserve your records and select one that is HIPAA-safe.

In the digital age, many are choosing to store records electronically. There are secure options available for electronic storage, but keep in mind that many cloud drive services (even the well-known ones) don’t follow HIPAA guidelines, no matter how you secure the information. And with frequent changes to their privacy policies and terms of service, you need to remain vigilant that any record storage service you use remains HIPAA-safe and fully secure.