Counselor´s Record Keeping System Essay

815 Words4 Pages
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…
No information can be given without Josephine’s information can be released without her written consent but there are exceptions to this rule. All hospitals and clinics have something call the privacy statement which describes how medical and psychological information can be used and disclosed which is needed to be reviewed before signing.
For counseling to continue, insurance information needs to be on file making sure that co-payments are made before counseling starts. So to continue with follow up, Josephine has to make sure that all information with payments is correct. If she has changed any information in regards to insurance, she will have to provide the correct information and any payments that are not made yet.
The focus of motivational therapy is to encourage Josephine to develop a bad view of what is going on so that she will want to and have the desire and willpower to change her behavior. What I have to do is to develop and express empathy, rolls with resistance, and supports self-efficacy. In addition to these I will also use reflective listening, observing differences between current and desired behavior, try to avoid arguments, communicate to her with respect, encourage her to believe that she is capable of change as well as be supportive and knowledgeable. I think it will be good to also compliment Josephine instead of condescending and also gently persuade her with understanding the change is up to her.
My schedule follow up with Josephine will
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