Personal Phone Records, a Subpoena, and a Boundary Slip
An LMT in Williston keeps client records as notes on a personal smartphone because the clinic's computer is shared. A client who received eight sessions for neck pain sends a text asking for a copy of her records and also invites the therapist to a family barbecue. The therapist has been exchanging friendly texts and once accepted a $100 gift card. The clinic receives a subpoena for the client's records in a workers' compensation dispute. The therapist's notes include abbreviations, no dates on two visits, and a comment that the client was 'difficult.' The clinic owner says the phone is personal, so the records are not clinic records. The therapist wants to delete the texts and send only a summary to the attorney.
1. Are the notes on the personal phone clinic records? What should happen with the client's request and the subpoena?
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Records: Client records are clinic records even if stored on a personal phone. The therapist should not delete texts or notes. The clinic should have a written records policy covering ownership, retention, and release. Request by client: The client is entitled to a copy under the clinic's release process, with proper identity verification and any permitted redactions for third-party information. Subpoena: A subpoena is not a casual request. The therapist should notify the clinic owner and legal counsel, preserve all records, and respond through the proper channel rather than sending a summary.
2. What are the boundary concerns raised by the texts, gift card, and barbecue invitation?
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Boundaries: Friendly texting and accepting a $100 gift card can blur the professional relationship. The barbecue invitation should be declined politely, and future communication should be limited to scheduling and care. Gift: A small gift may be acceptable under some policies, but a $100 gift card is substantial and should be disclosed to the supervisor. Reasoning: The issue is not that the client is 'difficult'; it is that the therapist's objectivity and the client's expectations may be affected. Document the boundary discussion factually.
3. How should the therapist address the deficient notes without creating new legal problems?
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Deficient notes: Missing dates, unexplained abbreviations, and a subjective label like 'difficult' weaken the record. The therapist should not alter the old notes retroactively; instead, add a dated addendum only for clarification. Subpoena response: Produce the complete records as required, not a curated summary. The attorney needs the actual notes, including the comment, because incomplete production can create legal risk. Retention: Follow the clinic's retention schedule and the Board's recordkeeping rules; do not destroy records while a subpoena is pending.