Practice Policies
Blue Mountain Wellness (BMW) in partnership with Wellness Massage & Lymphatic Drainage (WMLD)
Effective Date: June 1, 2025
1. Purpose
This policy outlines the recordkeeping and retention procedures for Blue Mountain Wellness (BMW) and Wellness Massage & Lymphatic Drainage (WMLD), operated respectively by Brandon Weimer, LMHC and Elizabeth Weimer, LMT, CLT. It ensures compliance with HIPAA, Washington State law, and professional standards for both mental health and massage therapy services.
2. Systems and Platforms Used
- Jane App: Used for electronic health records (EHR), documentation, intake forms, session notes, appointment tracking, and billing for BMW.
- Spruce Health: Used for secure communication, telehealth, texting, voicemail, and documentation for both BMW and WMLD.
- Square App: Used exclusively for payment processing and financial recordkeeping for WMLD (no clinical data stored).
3. Types of Records Maintained
- Intake forms and client contact information
- Informed consent, authorization, and policy acknowledgment forms
- Clinical notes (SOAP, DAP, or narrative format)
- Diagnosis and treatment planning (for mental health clients)
- Appointment history and communication logs
- Financial transactions and billing statements (in Jane or Square)
4. Timely Documentation
- Clinical notes must be completed within 24 hours of a session.
- Intake and consent documentation must be completed prior to initiating services.
- Communications, cancellations, or critical client interactions are logged within the appropriate platform (Jane or Spruce).
5. Record Retention Periods
In accordance with Washington State law:
- Records for adult clients must be retained for at least 3 years after the last service date.
- Records for minors must be retained until the client turns 21 (or 3 years after services end, whichever is later).
- Financial records are retained for a minimum of 7 years for audit and tax compliance.
6. Secure Storage and Disposal
- All records are stored in HIPAA-compliant systems with restricted access.
- Any paper documents are scanned and uploaded into Jane App or Spruce and then shredded within 30 days.
- Digital records are deleted using secure, irreversible deletion protocols once retention periods are met.
- Access is logged and reviewed to prevent unauthorized use.
7. Client Access and Requests
- Clients may request a copy of their records in writing.
- Requests must be fulfilled within 30 days unless an extension is requested.
- Clients may request corrections to their records. Approved corrections will be added to the original record.
- Clients may request restricted access or revoke prior authorizations.
8. Policy Review and Compliance
This policy is reviewed annually and updated to reflect changes in state or federal law, industry standards, or changes to clinical or administrative procedures. Brandon and Elizabeth are jointly responsible for ensuring all practices comply with this retention policy.
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