Establishment and Retention of Clinical Treatment Records

(1) Establishment of Clinical Treatment Records. A social worker who provides clinical social work services shall establish and maintain a separate, legible, adequate and accurate written clinical treatment record for each client receiving such services. This clinical treatment record shall be maintained in accordance with accepted standards of professional social work practice, shall identify the client to whom it pertains, and shall contain: (a) A description of the client’s prior history of services, if any; (b) A description of the client’s present reasons for seeking clinical social work services; (c) An assessment or diagnosis of the client’s mental, emotional or behavioral condition, disorder or addiction; (d) Documentation of any changes or revisions in the assessment or diagnosis of the client’s mental, emotional or behavioral condition, disorder or diagnosis which occur during the provision of clinical social work services by that social worker; (e) A treatment plan which sets forth the treatment goals and objectives established by the client and the social worker, describes the nature of the clinical social work services provided and identifies the treatment modalities used; (f) Documentation of any changes or revisions in the treatment plan which occur during the provision of clinical social work services to that client by that social worker; (g) A description of the frequency and duration of the services provided; (h) Progress notes containing the social worker’s assessment of the client’s progress in treatment; (i) Recommendations and/or plans for further treatment or services for the client, where appropriate; (j) Documentation of any fees charged, payments obtained, and other relevant billing and/or insurance information; (k) Documentation that the client has been informed of his or her confidentiality rights, as required by 258 CMR 22.05; (l) Copies of all client authorizations for release of information or records; and (MA REG. # 1355, Dated 12-29-17) (m) Any other information reasonably necessary to permit proper assessment and treatment of the client in the future. (2) Length of Record Retention. Except as otherwise provided by law, a client’s clinical treatment record shall be maintained for a period of not less than seven years from the date of the last client encounter or professional consultation with the client. In the event that the client is a minor, the client’s clinical treatment record shall be maintained for at least seven years from the date of the last client encounter or professional consultation with the client, or at least three years after the client attains the age of majority, as defined in M.G.L. c. 4, § 7, whichever is longer. (3) Client Access to Clinical Treatment Records. (a) Except as provided in 258 CMR 22.02(3)(b), a social worker shall, upon written request by a client or prospective client or an authorized legal representative of that client or prospective client, permit that client or prospective client or his or her authorized legal representative to inspect his or her clinical treatment record. Upon such a written request, the social worker shall also permit that client, or prospective client or his or her authorized legal representative to obtain a copy of that clinical treatment record. Unless otherwise prohibited by law, the social worker may charge a reasonable fee, not to exceed the actual cost of reproducing the cost of such record, for this service. (b) A social worker may decline to permit a client or prospective client to inspect or obtain a copy of his or her clinical treatment record if the social worker, in the reasonable exercise of his or her professional judgement, believes that allowing that client or prospective client to inspect or copy their clinical treatment record would adversely affect the physical or mental well-being of that client or prospective client. If a social worker declines to provide a copy of a client’s clinical treatment record to that client pursuant to 258 CMR 22.02(3), the social worker shall provide that client with a treatment summary, as defined in 258 CMR 8.03: Definitions, in lieu of the full clinical treatment record. If the client or prospective client still requests a copy of the full clinical treatment record, the social worker shall provide a copy of the full clinical treatment record to either an attorney designated by the client or a psychotherapist, as defined in M.G.L. c. 112, § 12CC, designated by that client.