Law & Ethics for Clinicians Working With Children & Families

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Sample HIPAA-Compliant HIPAA Compliant Record Patient name:__________________________ Date __________ Length of Session______ CPT: 90806; 90818; 90847; 90853; Other________ (Start___________ Finish __________) Diagnoses:________________________________________________ Axis IV Psychosocial and Environmental problems addressed: ____Primary support group problems ____Self-care problems ____Social environment problems ____Economic stressors ____Physical health problems ____Current victimization ____School/work problems ___Other psychosocial stressors ____Housing problems Current GAF__________; Highest GAF this year____________. Current Meds._____________________________________________. Risk issues assessed________________________________________. Consultations:_____________________________________________. Tx Plan___________________________________________________. Informed consent issues discussed this session:_________________ _________________________________________________________ (Signature)______________________________________
CLINICAL RECORD Client: Clinician: Prepared by Michaele P. Dunlap, Psy.D. for Pragmatics of HIPAA Training 2-28-03 Start Stop Tx Mode Summary recorded this session: (T) Tests/Results, (M) Med .(D) Diagnosis, (S) Symptoms (F) Functional Status (Tx P) Treatment plan, (Prog) Progress to Date (E) Prognosis Per Federal Regulation the above information is documented at each client visit, and may be used or disclosed upon specific written consent of the client or the client=s authorized representative for treatment, payment or healthcare operations. No other information about this client will be released by this mental health professional/mental health care entity unless specific, fully informed authorization from the client or an authorized representative is obtained in writing, or as otherwise allowed or required by law. Statutes and regulations in this State may be more restrictive than Federal Regulation, further limiting disclosure of the above and other individually identifiable health information. AS THE RECEIVING ENTITY, YOU MAY BE SUBJECT TO CIVIL AND FEDERAL CRIMINAL PENALTIES FOR IMPROPER RE- DISCLOSURE OF THIS INFORMATION.
Page 1 and 2: Law & Ethics for Clinicians Working
Page 3 and 4: Duty To Warn Hypothetical: 1. Blend
Page 5 and 6: Tarasoff Tarasoff 2: worser & worse
Page 7 and 8: Civil Code § 43.92 (The “Tarasof
Page 9 and 10: Post-Tarasoff Post Tarasoff Report
Page 11 and 12: Tarasoff Ewing v. Goldstein: A prob
Page 13 and 14: Third Party Lawsuits Hypothetical:
Page 15 and 16: Third Party Lawsuits 7. Just prior
Page 17 and 18: Third Party Lawsuits SO - WHO IS LI
Page 19 and 20: Third Party Lawsuits SO - WHO IS LI
Page 21 and 22: Abuse of Transference Hypothetical:
Page 23 and 24: Abuse of Transference Pt. also tell
Page 25 and 26: “Abuse of Transference” Creatin
Page 27 and 28: PROFESSIONAL RECORDS Hypothetical:
Page 29 and 30: Professional Records 9. Evaluator i
Page 31 and 32: Professional Records The standard o
Page 33 and 34: Professional Records & HIPAA You ne
Page 35 and 36: The “Clinical Clinical Record”
Page 37: Professional Records Centers for Me
Page 41 and 42: Sample HIPAA-Compliant HIPAA Compli
Page 43 and 44: Lunch Break We return at 1:00. Have
Page 45 and 46: Sample Suicide Assessment Format RI
Page 47 and 48: RISK FACTORS FACILITATING INHIBITIN
Page 49 and 50: High-Conflict High Conflict Divorce
Page 51 and 52: High-Conflict High Conflict Divorce
Page 53 and 54: Authorization for treatment of mino
Page 55 and 56: The “rules rules” Confidentiali
Page 57 and 58: AAMFT Ethics Code: Principle 3.14 (
Page 59 and 60: 5. ( ) I am a grandparent, aunt, un
Page 61 and 62: TO HEALTH CARE PROVIDERS AND HEALTH
Page 63 and 64: Regressive Impact of Regulatory Env
Page 65 and 66: A “New New Frontier” Frontier Y
Page 67 and 68: Ethics and Organizational Demands P
Page 69 and 70: Marriage/Family Therapy (AAMFT): Su

Law & Ethics for Clinicians Working With Children & Families

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