Falvey, J. E., & Cohen, C. R. (2003). First, the information provided to clients as part of the informed consent process at the onset of the professional relationship (Ethics Code, Standard 10.02) may include information about how the record is kept (e.g., jointly or separately) and who can authorize its release. In many cases, psychologists who maintain electronic records will be subject to the HIPAA Security Rule, which requires a detailed analysis of the risks associated with electronic records. 10 years after the last discharge, but master patient index data must be kept permanently. Often, rules for record creation and maintenance reflect requirements of all relevant disciplines, not only those related to psychological services. (2006). The Board of Directors approved the draft in principle on December 9, 2006, and COPPS further revised the draft, incorporating BPA's recommended changes, during its December 8-9, 2006 meeting and throughout the end of 2006. Collection. There may be limited opportunity to keep as detailed records as would be kept in a less urgent situation, particularly in the short-term or immediate crisis. COPPS also acknowledges the consultation of Lisa R. Grossman, Stephen Behnke, Lindsay Childress-Beatty, Billie Hinnefeld, and Alan Nessman. Such documentation may reflect the psychologist's basis for concluding, at the onset, that the arrangement is neither exploitative nor clinically contraindicated (Ethics Code, Standard 6.05). The psychologist considers HIPAA regulations regarding psychotherapy notes,3 the breadth of the records requested, and the client's wishes, along with the situational demands. Jacovino, L. (2004). We have developed administrative record keeping guidelines to make it easier for you to maintain good record keeping standards within your practice. Specialty and associate staff doctors' pay scales, Transitioning to the 2015 NHS pension scheme, Returning to the NHS or starting a new role, Refugees, overseas visitors and vulnerable migrants, Mental health of doctors and medical students. Retain until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment, or 8 years after death. Application: The psychologist is encouraged to update active records to reflect professional services delivered to the client and changes in the client's status. Health clinics must maintain client records for not less than five years. They are not definitive and they are not intended to take precedence over the judgment of psychologists. Mental health records, on the other hand, are considered to fall within general protected health information (PHI) and be part of the general health record. It is therefore helpful for psychologists to clarify these issues at the beginning of the relationship in order to minimize the likelihood of misunderstandings. Technological advances and telehealth: Ethics, law, and the practice of psychotherapy. it is important to note that client records must be kept and maintained in accordance with the state regulations. Psychologists are encouraged to participate in development and refinement of organizational policies involving record keeping. Legal issues in the professional practice of psychology. The listed retention periods are the minimum required length, and it is encouraged for providers to keep the records for a longer period of time, if possible. The psychologist may use various methods to organize records to assist in storage and retrieval. Treatment team involvement in service delivery may occasion wider access to records than usually exists in independent practice settings. COVID-19 resources for psychologists, health-care workers and the public. The psychologist is encouraged to carefully weigh these matters in making decisions to retain or dispose of records.7. Additionally, it is beneficial for the psychologist to retain information concerning the specific nature, quality, and rationale for services provided. The financial record for services may begin with a fee agreement or fee policy statement that identifies the amount to be charged for service and the terms of any agreement for payment. Considerations of record confidentiality are critical when planning for disposal of records. Information written in vague or broad terms may not be sufficient if more documentation is needed (e.g., for continuity of care, mounting an adequate defense against criminal, malpractice, or state licensing board complaints). COPPS reviewed the questions received from members by the APA Practice Directorate Legal and Regulatory Affairs Office and the APA Ethics Office about record keeping practices. Consistent with legal and regulatory requirements and ethical standards (e.g., Ethics Code, Standard 6.02; HIPAA Privacy Rule and Security Rule), psychologists employ procedures to limit access of records to appropriately trained professionals and others with legitimate need to see the records. Even though efforts to delete or erase records may be undertaken, the records may nevertheless remain accessible by those with specialized expertise. 7 8 9. Specific state and federal laws and regulations govern psychological record keeping. Benefield, H., Ashkanazi, G., & Rozensky, R. H. (2006). Record keeping guidelines. 20 years after date of last contact between the patient and the mental health provider. COPPS began with an assessment of APA member experience with the current guidelines. The use of email in a child and adolescent mental health service: Are staff ready? Decoding the ethics code: A practical guide for psychologists. You should tell NHS staff when your personal information changes or if you are going to be out of the UK for a long time. Alteration or destruction of records. Queensland State Archives Glossary of Archival and Recordkeeping Terms : Archiving ; The process of transferring inactive information, including records from an active system, to a repository for longer-term storage, preservation and access. Professional School Counseling, 8, 372-376. Koocher, G. P., & Keith-Spiegel, P. (1998). New York: Oxford University Press. Record keeping practices may depend upon the nature of the psychologist's legal relationship with the organization. Appropriate security procedures protect against the loss of or unauthorized access to the record, which could have serious consequences for both the client and psychologist.5 Access to the records is limited in order to safeguard against physical and electronic breaches of the confidentiality of the information. View all the latest news, blogs and features from the BMA. New York: Wiley. They are intended to facilitate the continued systematic development of the profession and to help facilitate a high level of practice by psychologists. Application: The psychologist strives to keep records in ways that facilitate authorized disclosures while protecting the privacy of clients. It does represent, however, a solid basis for consideration that, in combination with state and federal regulations, may provide an adequate framework for record keeping. Professional Psychology: Research and Practice, 37, 215-222. Rules and Regs. 6 years after last entry, or 3 years after the patient's death. Most commonly, these questions concerned the content of records, management and maintenance of records, electronic records, retention of records, and compliance with rapidly changing state and federal requirements for record keeping. Determination and documentation of the need for practice guidelines. The patient-therapist relationship: Reliable and authentic mental health records in a shared electronic environment. Although this guidance refers to minimum periods for which records must be retained, there may be times when records need to be kept for longer. For example, in transporting records to be shredded, the psychologist may take care that confidentiality of the records is maintained. Professional Psychology: Research and Practice, 34, 309-311. Parts 160 and 164 (2002). State and federal laws, as well as the American Psychological Association's (APA, 2002b) "Ethical Principles of Psychologists and Code of Conduct" (hereafter referred to as the Ethics Code), generally require maintenance of appropriate records of psychological services. Psychologists are familiar with the ethical standards regarding confidentiality, as well as state and federal regulations and statutes (e.g., HIPAA, licensing laws, mandated reporting of abuse). Parts 160, 162, and 164 (2003). In such a situation, the psychologist recognizes that the relevant court overseeing the marital dissolution may have already specified who has access to the child's treatment records. Where standards and legal and regulatory codes exist, they take precedence over these guidelines. A guide to the 2002 revision of the American Psychological Association's ethics code. American Psychologist, 57, 1048- 1051. In the case of the death or disability of the psychologist or of an unexpected transfer of the client's care to another professional, current, accurate, and organized records allow for continuity of care (see Guideline 13). This document aims to elaborate and provide assistance to psychologists as they attempt to establish their own record keeping policies and procedures. Remember, your records are confidential and secure when in our care; once you have a copy, you are responsible for the safe keeping of those documents. In considering the creation of records for couple, family, or group therapy, the psychologist may first seek to clarify the identified client(s). Psychologists who are subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) should be aware of certain record keeping requirements and considerations under HIPAA's Security Rule and Privacy Rule (see HIPAA Administrative Simplification, Regulation Text, 45 CFR Parts 160, 162 and 164; U.S. Department of Health and Human Services, Office for Civil Rights, 2006). Observations on the retirement of professional psychologists. Your health records. McMinn, M. R., Buchanan, T., Ellens, B. M., & Ryan, M. K. (1999). Documentation: Can you have too much of a good thing? The ease of creating, transmitting, and sharing electronic records may expose psychologists to risks of unintended disclosure of confidential information. Guidelines are aspirational in intent. Mental health records must be held for a minimum of thirty years. (2005). A psychologist may also consider, for purposes of convenience and organization, an additional section to include material generated by the client or by third parties, such as the client's family members, or from prior treatment providers. American Psychologist, 57, 1060- 1073. Archived by APA Council of Representatives in August 2019. Professional Psychology: Research & Practice, 19, 658-660. It would not be feasible to establish detailed guidelines for record creation, maintenance, and disposition that would be relevant for each setting. When a psychologist releases client records, with proper authorization to release information, they may be further distributed without the psychologist's or the client's consent. Organization of client records in a manner that allows for thoroughness and accuracy of records, as well as efficient retrieval, both benefits the client and permits the psychologist to monitor ongoing care and interventions. Ethics in psychology: Professional standards and cases. For example, a logical file labeling system facilitates the search and recovery of records. Application: The psychologist strives to protect the security of the paper and electronic records he or she keeps and is encouraged to develop a plan to ensure that these materials are secure.6 In the security plan, two elements to be considered are the medium on which the records are stored and access to the records. New York: Wiley. Until the patient's 25th birthday, or 26th if an entry was made when the young person was 17; or 3 years after death of the patient if sooner. Professional Psychology: Research and Practice, 37, 273-277. Rationale: The usefulness of psychological service records often depends on the records being systematically updated and logically organized. 8 years after the conclusion of treatment or death. 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