Course excerpt from Ethics & Risk Management: Expert Tips 8
There is a great difference between correcting and altering treatment records. Here’s what you need to know to be both legal and ethical:
Good records are needed for many reasons, and making sure they are accurate and correct is important. But, altering records is unethical and can lead a therapist into great trouble with licensing boards or the courts.
Reasons for keeping records:
- Good record keeping helps clinicians organize the treatment plan and enhances the quality of care.
- A record of treatment helps maintain a continuity of care when clients shift to new therapists.
- It protects clinicians in cases of board investigations, lawsuits, subpoenas, etc.
- It helps in the event of the therapist’s sudden disability, death, etc.
- And, keeping records is a mandated part of the standard of care.
Valid reasons for corrections:
- When there is an incorrect notation regarding diagnosis, CPT code, prognosis, type of intervention, client’s behavior, motivation, plans, dangerousness, etc.
- Accidentally writing a wrong word or term in the notes.
- A client makes a valid request to amend the records, a right that is an option for clients under HIPAA with Covered Entities (if the therapist agrees with the request).
Accurate records are very important:
- Records inform subsequent therapists and are critical for determining a continued course of treatment.
- Records can determine a client’s eligibility for disability, retirement, keeping a job, maintaining custody of a child, security clearance, capacity to stand trial, etc.
- Inaccurate or wrong records can be costly, particularly in litigation, for clients, therapists or other people involved.
There are no acceptable reasons for altering records, but some therapists attempt to alter records after they receive a subpoena or at the request of an attorney. Also, altering diagnoses or CPT codes so clients will be eligible for insurance reimbursement is clearly unethical and substandard care.
Erasing, deleting, removal, re-writing, wite-out, and similar ways of “correcting” records, where the original records are NO longer visible or adding content at a later date without indicating that changes took place are NOT acceptable and can be easily seen as an attempt to distort, conceal, hide, commit fraud or mislead.
Note that forensic experts may be able to detect altered typed-up clinical notes or EHR which have been tampered with. Altering records is unethical and below the standard of care and can result in licensing board discipline, a malpractice suit or a criminal investigation.
In summary, DO NOT alter records.
Ways of changing or correcting records are neither specified in law or regulation, nor in the codes of ethics.
Transparency seems to be a key issue. While HIPAA gives clients the right to review their records and request corrections, it does not specify how these corrections should be made (assuming the therapist agrees to make the requested changes).
Reasonable ways to correct records:
- If strikethrough is used, it should be made to the language to be changed, where the strikethrough original text is still readable.
- Indicate the date, time, reason and who initiates the change.
- Treat typed-up records as handwritten records, print them, sign, date and mark/highlight/initial/date the corrections or use a “track changes” program.
- Correct online/electronic health records as you would any printed or handwritten records.
- Finally, when in doubt, CONSULT (before you impulsively act).
Ethics & Risk Management: Expert Tips 8 is a 3-hour online continuing education (CE) course that addresses a wide variety of ethics and risk management topics, written by experts in the field. This online course provides instant access to the course materials (PDF download) and CE test. After enrolling, click on My Account and scroll down to My Active Courses. From here you’ll see links to download/print the course materials and take the CE test (you can print the test to mark your answers on it while reading the course document). Successful completion of the online CE test (80% required to pass, 3 chances to take) and course evaluation are required to earn a certificate of completion.
Professional Development Resources is approved to sponsor continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB Provider #1046, ACE Program); the American Occupational Therapy Association (AOTA Provider #3159); the Commission on Dietetic Registration (CDR Provider #PR001); the Alabama State Board of Occupational Therapy; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy (#BAP346), Psychology & School Psychology (#50-1635), Dietetics & Nutrition (#50-1635), and Occupational Therapy Practice (#34); the Ohio Counselor, Social Worker & MFT Board (#RCST100501); the South Carolina Board of Professional Counselors & MFTs (#193); and the Texas Board of Examiners of Marriage & Family Therapists (#114) and State Board of Social Worker Examiners (#5678).