Psychologists are required to keep records. Fortunately, there is some flexibility in the specifics of record keeping, depending on the setting, population served, and type of practice. Creating and maintaining records involves ethical decision-making to incorporate laws, ethics, guidelines, risk-management, clinical style, and personal preference. Evaluate your record keeping skills by envisioning your record being read by a third party at a deposition or by your patient.
In 2006, the Board of Psychology established “ as its standards of ethical conduct relating to the practice of psychology,” the APA Ethical Principles of Psychologists and Code of Conduct (2002), which included a standard about record keeping (APA 6.01). While the Ethics Codes are standards that are mandatory, the Record Keeping Guidelines provide 13 components of “a framework for making decisions…” (APA, 2007, p. 993). The following are seven important content areas addressed in this document.
1. Content of records . Maintain accurate, current, and pertinent records of professional services including information such as the nature, delivery, progress, and results of psychological services and related fees. (APA 6.01) There are three content areas: 1) Patient information including: identification; emergency contacts; fees and financial arrangements; documentation of verbal or written informed consent (APA 3.10); presenting problem; risk assessment; medical issues; and treatment plan. 2) Meaningful contact including: date; type; duration; and content of service. 3) Special occurrences including: emergencies; dangerousness; mandated reporting; collateral contact; waivers of confidentiality, and authorization to release information (APA 4.05). For termination, indicate the reason, who initiated and referrals given.
2. Disclose record keeping procedures and maintain confidentiality . Provide information regarding the nature and extent of record keeping procedures (including a statement on the limitations of confidentiality of the records (APA 4.01, 4.02).
3. Maintenance of records. Records are organized and maintained to ensure their accuracy and to facilitate use by the psychologist and others with legitimate access to them (APA 6.02).
4. Protection of records from unauthorized access, damage and destruction . Store and protect records, computers, disks, and external hard-drives in a fireproof and waterproof locked cabinet. (APA 6.02).
5. Retention of records : A “psychologist shall retain a patient’s health service records for a minimum of seven years from the patient’s discharge date. If the patient is a minor, the patient’s health service records shall be retained for a minimum of seven years from the date the patient reaches 18 years of age.” (B&P Code 2919).
6. Electronic records . Records are created and maintained to protect their security, integrity, confidentiality, and provide appropriate access. Computers should be encrypted, with password and virus protection. Information should be backed up on a disk or external drive or printed out and stored as a written record.
7. Disposition of Records . Establish a plan for transfer of records to ensure continuity of care and appropriate access to records when the psychologist is no longer in direct control and, in planning for record disposal, the psychologist endeavors to employ methods that preserve confidentiality and prevent recovery. (APA 6.02c).
Please see the APA Record Keeping Guidelines (2007) for a complete description.
References used in this article may be obtained by request from the LACPA office: [email protected]