Counselor´s Record Keeping System Essay

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A clear, well-organized record-keeping system is essential for counselor who provides treatment, nutritional assessment and consultation services. But setting up such systems can be challenging. For one, a counselor need to attack the fine balance between the need to maintain client privacy and confidentiality and the need to communicate with insurers, other treating professionals and larger health systems. Counselor’s records must also follow the state and federal laws (King & Klawitter, 2007). . In addition, a counselor needs to plan for retirement and the eventual disposal of records. In order for counselor to have these records, information needs to be documented. Some of the things that need to be documented include counseling …show more content…
A clear, well-organized record-keeping system is essential for counselor who provides treatment, nutritional assessment and consultation services. But setting up such systems can be challenging. For one, a counselor need to attack the fine balance between the need to maintain client privacy and confidentiality and the need to communicate with insurers, other treating professionals and larger health systems. Counselor’s records must also follow the state and federal laws (King & Klawitter, 2007). . In addition, a counselor needs to plan for retirement and the eventual disposal of records. In order for counselor to have these records, information needs to be documented. Some of the things that need to be documented include counseling sessions, patient family history, payment history, emergency contact and patient’s vitals, privacy act, informed consent, past and present medical history.
All information for all clients are kept confidential and these can be schedule of appointments, counseling session contents, any information that contain records and the outcome of the counseling are confidential by State law (King & Klawitter, 2007). This type of confidential services is provided and maintained by all medical personals. Josephine’s record consists of both paper file and electronic database components. Her records are much secured, physically and electronically, thus protected by the same confidentiality and privacy laws. Most counseling centers have patients that see more
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