Mental Health Records

PSYCHOLOGY

Mental Health Records Keeping

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PSYCHOLOGY

Mental Health Records Keeping

In comparison to other forms of medical billing, medical health professionals find it difficult to

file insurance claims related to mental health illness. This is because the process mainly deals

with therapy sessions as opposed to physical examination thus making it difficult to determine

accurate cost of treatment. In order for successful billing to take place, mental health

professionals should accurately determine the number of therapy sessions and treatment period

(Holis at al., 2015). Therefore, private counselors process their own bills to avoid incurring

additional costs of treatment. Mental health professionals use the records to double-check the

patient’s insurance before every visit and use the insurance company’s appropriate filling

methods to ensure that the claims for mental healthcare are approved.

Mental health patients have the right to privacy of their mental records. Mental health

professionals cannot disclose this information to other people including family members without

the informed consent of the patient. However, there are other mental health records information

that can be disclosed by mental professionals such as the diagnosis of the patient, the

recommended treatment and its frequency, counselling and medication sessions, clinical test

results, prognosis and monitoring among others (Kahn, Bell, Walker & Delbanco, 2014).

Another right is confidentiality that ensures that professionals guarantee the safety of the

patients’ mental health records. In order to disclose this information, the mental health

professional must obtain a written consent of the patient.

The mental health professionals comply to the HIPAA law. The Health Insurance Portability and

Accountability Act or HIPAA protects the mental health records of patients by ensuring their

privacy. This privacy rule also protects the transferring, utilizing or selling mental health

information (Hollis et al., 2015). Even though the privacy rule allows the care providers to

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disclose patients’ health records to family members, this cannot take place if the patient objects.

However, even if the patient objects, the mental health records disclosed to family members

should only be limited to the information that is necessary for taking good care of the patient.

During the counselling period, the mental health professional has the obligation to provide all

forms of information and health records required for the client’s informed consent as mandated

by the state laws and practices. The informed consent form highlights the policies governing the

relationship between the counsellor and client’s rights according to the state and federal laws.

This form should be made available to the client whenever it is requested for. The client is

expected to sign the informed consent form before the beginning of the therapy sessions and

adhere to the provisions of the form (Kahn, Bell, Walker & Delbanco, 2014). Some of the

oversight requirement for informed consent include the identity of the client, confidentiality, how

to deal with emergency situations, coordination of treatment, financial issues as well as the

consent for treating minors.

Client record keeping plays a crucial role in ensuring the safety of client mental health

records. This practice is mainly governed by the HIPAA privacy rule and ensures that the mental

records are not disclosed to unauthorized persons. Additionally, HIPAA put across rules that

govern sharing of mental health information to ensure that patients receive high quality care.

According to HIPAA privacy rule, patients have the right of inspecting, reviewing and receiving

copies of their mental records. However, they are not allowed to have access to psychotherapy

notes (Holis et al, 2015). These notes mainly comprise of confidential information gathered by

mental health professionals during private counselling sessions with the patients or their family

members. The patients cannot review or inspect these records because they are not included in

the billing or medical records. Additionally, to a professional standard core, client’s record

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keeping ensures that the mental professions do not disclose confidential information issued by

the client. Consequently, the client has to authorize the release of this information to family

members or partners.

Electronic medical records have several advantages and disadvantages. One of the

disadvantage is that the information that is extremely confidential can be accessed through data

leaks and breaches, for instance, the condition of the patient. Evidently, the software used to

store electronica medical data also acts as a good pharmaceutical advertisement platform thus

increasing the chances of unauthorized access of patients’ information (Caine & Tierney, 2015).

The cost for acquiring and maintaining the system is high and requires extensive training for

medical professionals to use it effectively. The advantage of the electronic medical record

keeping is that it allows mental health professionals to monitor treatment guidelines in order to

avoid medication mistakes. The system also has a large storage capability and information can be

retrieved immediately due to continuous updates of patients’ health records.

Electronic medical records contain large volumes of private information that thieves can

access thus some strategies have been put across to improve data security. The use of decryption

is used when patients view their personal details to ensure safety of the information from

unauthorized access of information by use of digital signatures (Caine & Tierney, 2015).

Incorporating user names and passwords are also effective methods of prevention electronic

medical data breaches. There are also other security techniques that are currently used to prevent

data breach such as initial risk assessment programs, radio frequency ide notification and

antivirus software among others. The clients can easily access this information using mobile

agents that have been secured for transmission of the patients records from one facility to

another. The role-based access controls ensure that only authorized patients can access the

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information passwords that are recognized by the system. Evidently, electronic health records

can also be viewed using mobile devices such as smartphones and personal computers that

patients can use effectively. The IT professionals assists patients to access their electronic health

records from the interface by creating an account, usernames and passwords for the patients. This

also includes educating the patients on how to access different categories of information from the

system.

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References

Caine, K., & Tierney, W. M. (2015). Point and counterpoint: patient control of access to data in

their electronic health records. Journal of General Internal medicine, 30(1), 38-41).

Hollis, C., Morris, R., Martin, J., Amani, S., Cotton, R., Denis, M., & Lewis, S. (2015).

Technological innovations in mental healthcare: harnessing the digial revolution.

Kahn, M. W., Bell, S. K., Walker, J., & Delbanco, T. (2014). Let’s show patients their mental

health records. JAMA, 311(13), 1291-1292.

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