Record Keeping System Policy
DR. PAULSON PROFESSIONAL COUNSELING LLC
Policy Director: Dr. Brian Paulson, Ph.D., LMHC-QS, LMFT-QS, LPC, MCAP, CGAC, Continuing Education Director & Primary Contact
Policy Mandate: This policy establishes the requirements for documenting, storing, retrieving, and protecting all mandated clinical client records (Chapter 491, F.S.) and Continuing Education (CE) Program documentation, ensuring compliance with state boards, FCB, NAADAC, and NBCC.
I. Record Custody and Retention Requirements
Dr. Paulson maintains responsibility for all client and CE records. The retention period for all records is governed by the most stringent standard applicable.
Record Category | Minimum Retention Period | Governing Authority |
Clinical Client Records | seven years after the date of the last contact with the client or user. | F.S. §491.0148 and Rule 64B4-9.001 (Florida Board). |
Continuing Education (CE) Records | five years following each offering of the program. | NBCC Policy Section C.10. (This exceeds the Florida Board minimum of three years and the FCB minimum of four years). |
II. Clinical Record Documentation Standards
Clinical documentation must include the client’s consent to all aspects of treatment, copies of all client authorizations for release of information, any legal forms, and documentation of any contact the therapist has with other professionals regarding the client. If requested in writing by the client, copies of tests, reports, or documents prepared for and paid for by the client, or a report of examination and treatment in lieu of copies of psychotherapeutic records, must be released without conditioning release upon payment of a fee for services rendered.
III. Continuing Education Program Documentation
To satisfy FCB, NAADAC, and NBCC requirements, a secure system is maintained to store the following documents for all continuing education programs offered for a minimum five-year period:
Required Course Documentation | Compliance Details |
Course Outline / Curriculum | Must include a detailed content outline reflecting educational objectives. The content must be directly relevant to the professional knowledge and skills of graduate-level counselors and must be clinically sound. |
Detailed Agenda & Timing | Must specify content and time frames for instruction, ensuring that one CE hour equals sixty minutes, with no less than fifty minutes of uninterrupted instruction. |
Presenter Documentation | Name, Curriculum Vitae (CV), and documentation of qualifications. The instructor must possess extensive experience (no less than two years of practical application or research) or hold the required academic qualifications (Ph.D./Faculty Member status) for the subject taught. |
Participant Roster | A list of participants by first and last name and license number. |
Course Evaluations | Original participant evaluations, including a rating scale for satisfaction/dissatisfaction with content, presenter skills/knowledge, facility (if live), materials, and relevance. A summary of evaluations must also be retained. |
Completion Certificates | A sample document must include the participant’s name, provider’s name and number (50-___), program title, date of program, and number of CE hours earned. Must include the statement: “Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling Provider Number 50-___.” |
Promotional Materials | Copies of all advertisements used to promote the program, conspicuously displaying the complete provider number (50-___), objectives, and presenter credentials. |
IV. System Security and Regulatory Compliance
These policies and records are maintained within a Secure Share Drive (Secured/Encrypted Cloud Storage), ensuring complete and accurate backup copies are maintained securely.
1. Electronic Reporting (CE Broker): Course completion credit data (rosters) must be submitted electronically via the CE Broker platform within thirty calendar days of completion.
2. Confidentiality: A policy is maintained concerning the confidentiality and security of participant information (name, address, email, telephone number, financial information). Disclosure or use of client information in a CE program is strictly prohibited without proper consent.
3. Audit Compliance: The system is prepared to provide all required records to comply with audit requests from the Florida Board or FCB within twenty-one days of receipt of such requests. Failure to make relevant records available may constitute grounds for disciplinary action.
4. Legal Matters Reporting (NBCC): Dr. Paulson must report involvement in any criminal investigation or case, civil court matter, or government agency matter to NBCC within thirty days of the date he knew, or should have known, about the matter.