(1)
Establishment of Clinical
Treatment Records. A social worker who provides clinical social
work services shall establish and maintain a separate, legible, adequate and
accurate written clinical treatment record for each client receiving such
services. This clinical treatment record shall be maintained in accordance with
accepted standards of professional social work practice, shall identify the
client to whom it pertains, and shall contain:
(a) A description of the client's prior
history of services, if any;
(b) A
description of the client's present reasons for seeking clinical social work
services;
(c) An assessment or
diagnosis of the client's mental, emotional or behavioral condition, disorder
or addiction;
(d) Documentation of
any changes or revisions in the assessment or diagnosis of the client's mental,
emotional or behavioral condition, disorder or diagnosis which occur during the
provision of clinical social work services by that social worker;
(e) A treatment plan which sets forth the
treatment goals and objectives established by the client and the social worker,
describes the nature of the clinical social work services provided and
identifies the treatment modalities used;
(f) Documentation of any changes or revisions
in the treatment plan which occur during the provision of clinical social work
services to that client by that social worker;
(g) A description of the frequency and
duration of the services provided;
(h) Progress notes containing the social
worker's assessment of the client's progress in treatment;
(i) Recommendations and/or plans for further
treatment or services for the client, where appropriate;
(j) Documentation of any fees charged,
payments obtained, and other relevant billing and/or insurance
information;
(k) Documentation that
the client has been informed of his or her confidentiality rights, as required
by
258
CMR 22.05;
(l) Copies of all client authorizations for
release of information or records; and
(m) Any other information reasonably
necessary to permit proper assessment and treatment of the client in the
future.
(2)
Length of Record Retention. Except as otherwise
provided by law, a client's clinical treatment record shall be maintained for a
period of not less than seven years from the date of the last client encounter
or professional consultation with the client. In the event that the client is a
minor, the client's clinical treatment record shall be maintained for at least
seven years from the date of the last client encounter or professional
consultation with the client, or at least three years after the client attains
the age of majority, as defined in M.G.L. c. 4, § 7, whichever is
longer.
(3)
Client
Access to Clinical Treatment Records.
(a) Except as provided in 258 CMR
22.02(3)(b), a social worker shall, upon written request by a client or
prospective client or an authorized legal representative of that client or
prospective client, permit that client or prospective client or his or her
authorized legal representative to inspect his or her clinical treatment
record. Upon such a written request, the social worker shall also permit that
client, or prospective client or his or her authorized legal representative to
obtain a copy of that clinical treatment record. Unless otherwise prohibited by
law, the social worker may charge a reasonable fee, not to exceed the actual
cost of reproducing the cost of such record, for this service.
(b) A social worker may decline to permit a
client or prospective client to inspect or obtain a copy of his or her clinical
treatment record if the social worker, in the reasonable exercise of his or her
professional judgement, believes that allowing that client or prospective
client to inspect or copy their clinical treatment record would adversely
affect the physical or mental well-being of that client or prospective client.
If a social worker declines to provide a copy of a client's clinical treatment
record to that client pursuant to 258 CMR 22.02(3), the social worker shall
provide that client with a treatment summary, as defined in
258 CMR 8.03:
Definitions, in lieu of the full clinical
treatment record. If the client or prospective client still requests a copy of
the full clinical treatment record, the social worker shall provide a copy of
the full clinical treatment record to either an attorney designated by the
client or a psychotherapist, as defined in M.G.L. c. 112, § 12CC,
designated by that client.
