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Ask Our Attorney: Record Keeping (Part II) When a Client Wants Access to Records

FOCUS - National Association of Social Workers (Mass. Chapter) Barry Mintzer July 1, 2007

I still receive calls from social workers wanting to know what to do when a client asks for a copy of their treatment records.  Typical questions and comments include: “Do I have to provide them?” “They aren’t very thorough;” “There is information I don’t want the client to see;” “I don’t think the client can emotionally handle reading the record.”  I wrote an article for an earlier FOCUS on a social worker’s legal and ethical obligation to maintain records, so I won’t rehash that here, other than to say that you are required to keep records of a certain type in a certain manner.  If you want a refresher, go to the record keeping regulations at the Board of Registration of Social Workers web site or see the prior FOCUS article.

Massachusetts law requires a social worker to provide a client or the client’s authorized legal representative, on written request, an opportunity to inspect his or her clinical treatment record and/or to obtain a copy of that clinical treatment record.  You may charge a reasonable fee, but it cannot exceed the actual cost of reproducing the record.  If the record is requested for the purpose of supporting a claim or appeal under any provision of the Social Security Act or any federal or state financial needs based benefit program, you cannot charge anything.  Records should be provided within thirty days of the request under any circumstance.

There is an exception if the social worker reasonably believes allowing the client to inspect or copy their clinical treatment record would adversely affect the client’s physical or mental well-being.  In such a case, you may provide the client with a clinical treatment summary in lieu of the full clinical treatment record.  The Board of Registration defines a clinical treatment summary as, “a written document which provides information about a social worker-client relationship and the nature and extent of any clinical social work services provided to that client, but does not include the substantive content of any communications made to the social worker during the course of, or in connection with, the performance of the social worker’s clinical social work services or any other materials which would otherwise reflect the thoughts, feelings or impressions of the client obtained or revealed during the provision of those clinical social work services.”

If the client still requests a copy of the full clinical treatment record, you are required to provide it either to an attorney designated by the client or a “psychotherapist” designated by that client.  In this context, psychotherapist means another licensed mental health practitioner.

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