Following internal policies and procedures

“Adhere to internal policies or standard operating procedures (SOPs) relevant to your clinical practice (e.g., informed consent, record retention, release of information, mandated reporting protocols)” (NBCC, 2027 task 6.2)

Agencies and practices have written policies and standard operating procedures for informed consent, records, releases of information, mandated reporting, risk management and more. Following them protects clients, ensures consistent care and reduces legal risk. The exam tests the role of internal policies and what to do when policy and ethics seem to conflict.

Key points

SOPs commonly cover informed consent, record retention and destruction, release of information, mandated reporting, suicide risk procedures, emergencies, telehealth and documentation timelines.
Policies translate law and ethics into specific steps for a setting; know and follow them.
Where policy is silent or unclear, consult a supervisor or compliance officer and document the decision.
When an agency policy conflicts with the ethics code, the ACA Code (D.1.h) asks counselors to alert their employers to inappropriate policies and to work through appropriate channels to change them.
Following an agency's reporting protocol does not replace a counselor's personal legal duty; in many states the mandated reporter must make the report directly.
Policies are reviewed and updated as laws and practices change; stay current.
New staff should receive orientation to key policies, and compliance should be monitored.

In practice

A counselor suspects child abuse. Her agency's protocol asks her to inform her supervisor and complete an internal form. She does both, and she also makes the report to child protective services herself within the time her state requires, because the duty is hers.

A new agency policy would allow sharing full session notes with case managers without client consent. A counselor raises concerns about confidentiality with her director and the compliance officer and proposes a narrower policy.

Check yourself

Why do agencies have standard operating procedures?

To translate laws and ethics into consistent, specific steps that protect clients and reduce risk.

Does informing a supervisor satisfy a counselor's mandated reporting duty?

Not necessarily, because in many states the duty is personal and the counselor must report directly to the authorities.

What should a counselor do if an agency policy conflicts with the ethics code?

Raise the concern with the employer and work through appropriate channels to change the policy.

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.