4 Colo. Code Regs. § 744-1.17

Current through Register Vol. 47, No. 7, April 10, 2024

Section 4 CCR 744-1.17 - RECORDS REQUIRED TO BE KEPT AND RECORD RETENTION (C.R.S. sections 12-245-204(4), 12-245-224(1)(u))

A. General.

Every certified addiction counselor and licensed addiction counselor shall create and shall maintain a record as defined in subsection (B) of this Rule for each client, this record shall be retained for a period of seven years, commencing on either the termination of professional counseling services or the last date of treatment with the client, whichever is later. Exception. When the client is a child, the record shall be retained for a period of seven years commencing either upon the last date of treatment or when the child reaches eighteen years of age, whichever comes later.

B. Record.

Every addiction counselor shall maintain, as applicable to the mental health services provided, a record containing the following information:

1. Name of treating therapist;

2. Client's identifying data to include name, address, telephone number, gender, date of birth, and if applicable the name of the parent or guardian. If the client is an organization, the name of the organization, telephone number and name of the principal authorizing the mental health provider's services or treatment;

3. Reason(s) for the psychotherapy services;

4. Mandatory disclosure statement(s);

5. Dates of service including, but not limited to the date of each contact with client, the date on which services began, and the date of last contact with client;

6. Types of service;

7. Fees;

8. Any release of information;

9. The records must be legible and prepared in a manner that allows any subsequent provider to yield a comprehensive conclusion as to what occurred;

10. Name of any test administered, each date on which the test was administered, and the name(s) of the person(s) administering the test;

11. Information on each referral made to, and each consultation with another therapist or other health care provider. This information shall include the date of referral or consultation, the name of the person to whom the client was referred, the name of the person with whom consultation was sought, the outcome (if known) of the referral, and the outcome (if known) of the consultation;

12. Records of counseling, interview notes, correspondence, audio or visual recordings, electronic data storage, and other documents considered professional information for use in counseling; and

13. A final closing statement (if services are over).

C. Record Storage.

Every certified or licensed addiction counselor shall keep and store client records in a secure place and in a manner that both assures that only authorized persons have access to the records and protects the confidentiality of the records, and of the information contained of the records.

D. Transfer of Records.

Whenever an addiction counselor deems it necessary to transfer her/his records to another certified or licensed addiction counselor or other health care provider, the certified or licensed addiction counselor making the transfer shall obtain the client's consent to transfer (when possible).

E. Disposition of Records.

If the certified or licensed addiction counselor is not available to handle her/his own records, the certified or licensed addiction counselor and/or his estate shall designate an appropriate person to handle the disposition of records. A plan for the disposition of records shall be in place for all certified or licensed addiction counselors for the following conditions:

1. Disability, illness or death of the certified or licensed addiction counselor.

2. Termination of the certified or licensed addiction counselor's practice.

3. Sale or transfer of a practice.

F. Record Destruction.

Every certified or licensed addiction counselor shall dispose of client records in a manner or by a process that destroys or obliterates all client identifying data. However, records cannot be destroyed until after seven years or as otherwise provided in these rules or any other applicable statutes.

G. Record keeping in agency/institutional setting.

An addiction counselor need not create and maintain client records if the certified or licensed addiction counselor practices in an agency or institution, and if the certified or licensed addiction counselor:

1. Sees the client in the usual course of that practice;

2. Keeps client records as required by the agency or institution; and

3. The agency or institution maintains client records.

4 CCR 744-1.17

43 CR 21, November 10, 2020, effective 11/30/2020

44 CR 09, May 10, 2021, effective 5/30/2021

44 CR 20, October 25, 2021, effective 11/14/2021

45 CR 05, March 10, 2022, effective 3/30/2022

45 CR 20, October 25, 2022, effective 11/14/2022