10.7 Record Keeping

As discussed in Chapter 7, counselors are ethically and legally obligated to keep confidential records of their sessions with clients. Notes serve as a compiled record of the treatment process, outcomes, progress to justify insurance coverage, and tangible data that clients can access (Koocher, 2003). Minors’ parents or legal guardians can access their child’s health information and medical records under HIPAA regulations (Ford-Sori, 2015). This does not apply to minor clients participating in substance use treatment, as their data is protected from parent(s)/ guardian(s) under 42 CFR part 2 (Koocher, 2003). Some states also have legal statutes that ban mental health records from parent/ guardian access (Ford-Sori, 2015).

Further exceptions to parental access include legally emancipated minors and notes regarding specific medical conditions (pregnancy, diagnosis, and treatment of sexually transmitted infections) (Koocher, 2003). When counselors create notes for minor clients, they are mindful that parents may access the information and include only necessary information with their client’s best interest in mind. Counselors are responsible for consulting all relevant policies and ethical codes.