Using electronic health records

“Use an electronic health record (EHR) or electronic medical record (EMR) system” (NBCC, 2027 task 6.18)

Most counselors now document in an electronic health record (EHR) or electronic medical record (EMR). These systems improve access and coordination but bring obligations for security, accuracy and client access. The exam tests sound EHR practice and related federal rules.

Key points

Choose an EHR that meets HIPAA requirements, signs a business associate agreement, and provides access controls, audit trails and backups.
Use role-based access so staff see only what their job requires, and never share log-in credentials.
Complete documentation promptly in the system and avoid copying and pasting from earlier notes without updating them.
Corrections should use the system's amendment features, leaving an audit trail.
Clients have a HIPAA right of access to their records, generally within 30 days of the request, with a possible 30-day extension; psychotherapy notes kept separately are excluded.
The 21st Century Cures Act information blocking rules mean many clients can see parts of their records electronically, so write notes with that in mind.
Plan for downtime: how to document and access critical information if the system fails.

In practice

A counselor notices that her agency's EHR shows full counseling notes to front desk staff. She raises it with the privacy officer, who adjusts permissions so scheduling staff can see only appointment information.

A client asks for a copy of her records through the patient portal. The counselor confirms the request process, provides the record within the required time, and explains that separately kept psychotherapy notes are not part of the release.

Check yourself

Why use role-based access in an EHR?

It limits each user to the information needed for their job, protecting confidentiality.

Within what period must a HIPAA covered entity generally respond to a client's request for access to records?

Within 30 days, with one possible 30-day extension.

Why is careless copying and pasting in EHR notes a problem?

It can create inaccurate records that do not reflect the actual session and may not support billing.

NBCC's knowledge and skills for Domain 6

Knowledge of: State laws (state licensure law, supervision requirements, abuse reporting, license renewal, CAQH); Federal laws (e.g., HIPAA, FERPA, immigration policy, HI-TECH, ADA, NPI); Codes of ethics; Third-party reimbursement, insurance and billing (e.g., CPT codes); Counseling Compact; Emerging technologies in Counseling; Crisis policies and procedures; Recording keeping and reporting requirements and procedures; Appropriate logistics for telemental health services; Scope of practice (e.g., letters of support, working with special populations); Alternative medical-assisted/pharmacological interventions; Accessing state licensure board; Executing voluntary and involuntary commitments.

Skill in: Maintaining confidentiality; Discerning reputable training providers and programs; Troubleshooting technological difficulties during telemental health session (e.g., session disconnects, video not working); Billing and third-party reimbursement.

A study guide written by ExamDragon from NBCC's published task; not NBCC material and not part of the exam.