Code of Colorado Regulations
700 - Department of Regulatory Agencies
726 - Division of Professions and Occupations - State Board of Social Work Examiners
4 CCR 726-1 - SOCIAL WORK EXAMINERS RULES AND REGULATIONS
Section 4 CCR 726-1.16 - RECORDS REQUIRED TO BE KEPT AND RECORD RETENTION (C.R.S. sections 12-245-204(4), 12-245-224(1)(u))

Universal Citation: 4 CO Code Regs 726-1 § 16

Current through Register Vol. 47, No. 17, September 10, 2024

A. General. Except as provided in subsection (G) of this Rule, every social worker shall create and shall maintain records on each of their social work/psychotherapy clients. Every social worker shall retain a record, as defined in subsection (B) of this Rule, on each social work/psychotherapy client for a period of seven years, commencing on the termination of social work/psychotherapy services or on the date of last contact with the client, whichever is later.

B. Record. Every social worker shall create and shall maintain a record for each social work/psychotherapy client. Every social worker shall retain a record on each social work/psychotherapy client for a period of seven years. A record shall contain, as applicable to the mental health services rendered, at least the following information:

1. Name of treating therapist.

2. Client's identifying data to include name, address, telephone number, gender, date of birth, and if applicable the name of the parent or guardian. If the client is an organization, the name of the organization, telephone number and name of the principal authorizing the mental health provider's services or treatment;

3. Reason(s) for the psychotherapy services;

4. Mandatory disclosure statement.

5. Dates of service including, but not limited to the date of each contact with client, the date on which services began, and the date of last contact with client;

6. Types of service;

7. Fees;

8. Any release of information;

9. The records must be prepared in a manner that allows any subsequent provider to reasonably conclude what occurred;

10. Name of any test administered, each date on which the test was administered, and the name(s) of the person(s) administering the test;

11. Information on each referral made to and each consultation with another social worker or other health care provider. This information shall include the date of the referral or consultation, the name of the person to whom the client was referred, the name of the person with whom consultation was sought, the outcome (if known) of the referral, and the outcome (if known) of the consultation;

12. A final closing statement (if services are over), if applicable.

D. Record Storage. Every social worker shall keep and store client records in a secure place and in a manner that both assures that only authorized persons have access to the records and protects the confidentiality of the records and of the information contained in the records.

E. Transfer of Records. Whenever a social worker deems it necessary to transfer their client records to another social worker or other health care provider, the social worker making the transfer shall obtain the client's consent to the transfer (where possible).

F. Disposition of Records. If the social worker is not available to handle their own records, the social worker and/or their estate shall designate an appropriate person to handle the disposition of records. The social worker or the estate designated representative shall make a reasonable effort to notify the primary client(s) of the disposition. A plan for the disposition of records shall be in place for all social workers for the following conditions:

1. Disability, illness, or death of the social worker;

2. Termination of social worker's practice; and

3. Sale or transfer of practice.

G. Record Destruction. Every social worker shall dispose of client records in a manner or by a process that destroys or obliterates all client identifying data. However records cannot be destroyed until after seven years or as otherwise provided in these Rules or any other applicable statute.

H. Record keeping in agency/institutional settings. A social worker need not create and maintain separate client records if the social worker practices in an agency or institutional setting and the social worker:

1. Sees the client in the usual course of that practice;

2. Keeps client records as required by the agency or institution; and

3. The agency or institution maintains client records.

Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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