This is a clone of the Texas Administrative Code (TAC) for educational purposes. It is not the official version and should not be used for legal purposes. Site created Wed, 21 May 2025 21:16:46 GMT
(a) This subsection applies to counseling records of an LCDC's private practice. Documentation of professional services rendered in another setting shall be created and maintained in accordance with any legal requirements for documentation applicable to the particular setting in which they were provided.(1) The counselor shall establish and maintain a record for every client at the time of initial service delivery. The client record shall include:(A) client identifying information;(B) assessment results, including a statement of the client's problems and/or diagnosis;(C) plan of care;(D) documentation of all services provided, including date, duration, and method of delivery; and(E) a description of the client's status at the time services are discontinued.(2) The counselor shall maintain a record of all charges billed and all payments received.(3) All entries shall be permanent, legible, accurate, and completed in a timely manner.(4) All documents and entries shall be dated and authenticated. Authentication of electronic records shall be by a digital authentication key.(5) When it is necessary to correct a record, the error shall be marked through with a single line, dated, and initialed by the counselor.(6) The counselor shall protect all client records and other client-identifying information from destruction, loss, tampering, and unauthorized access, use or disclosure. Electronic client information shall be protected to the same degree as paper records and in accordance with applicable law and accepted security standards for electronic health records prevailing at the time, and shall have a reliable backup system.(7) The counselor shall comply with all applicable state and federal laws relating to confidentiality, including the requirements of Texas Health and Safety Code, Chapter 611 (relating to Mental Health Records) and Code of Federal Regulations,