Retention of Client Records; Disposition of Client Records in Case of Death or Incapacity of Licensee
In this rule, “client record” means information maintained in a written or electronic form regarding treatment or billing of a client.
A regulated social worker who serves clients outside of an agency setting must ensure that a client record is maintained for each such client and that all client records are legible and are kept in a secure, safe, and retrievable condition. At a minimum, a client record must include an assessment of the client, a treatment or intervention plan, and progress notes of therapy sessions, all of which should be recorded concurrently with the services provided.
Retention of records. A regulated social worker must retain a client record for seven years from the date of the last session with the client.
A regulated social worker in private practice must make necessary arrangements for the maintenance of and access to client records that ensure the clients’ right to confidentiality in the event of the death or incapacity of the licensee. In regard to this requirement:
The regulated social worker must name a qualified person or appropriately qualified records management company to intercede for client welfare and to make necessary referrals, when appropriate.
The regulated social worker must keep the board informed of the name of the qualified person or records management company.
The board will not release the name of the qualified person or records management company except in the following cases:
The death or incapacity of the regulated social worker
A client is unable to locate the regulated social worker.
To be a qualified person under this rule a person must be a Licensed Clinical Social Worker or other licensed mental health professional licensed under Oregon law or a certified alcohol and drug abuse counselor.