Record keeping in psychotherapy and counseling: Protecting confidentiality and the professional relationship. The manner in which records are maintained may potentially affect the client in ways that may be unanticipated by the client. View the latest press releases from our England, Northern Ireland, Scotland and Wales media teams. Professional Psychology: Research and Practice, 37, 215-222. American Psychiatric Association. The federal and provincial governments have legislation pertaining to access to any personal information, including medical and mental health records. Complete medical records must be retained 2 years after the age of majority (i.e., until patient turns 20). We have developed administrative record keeping guidelines to make it easier for you to maintain good record keeping standards within your practice. Psychologists strive to be aware of the legal and regulatory requirements governing the release of information (e.g., some jurisdictions prohibit the re-release of mental health records, records of sexually transmitted diseases, or chemical dependency treatment records). Professional Psychology: Research and Practice, 35, 201-205. The paper office (3rd ed.). Record keeping practices may depend upon the nature of the psychologist's legal relationship with the organization. 20 years or 8 years after the patient has died. BPA approved the draft in principle and placed it on the agenda for Board of Directors approval in principle during its December 8-9, 2006 meeting. (2006). In the event that there are conflicts between an organization's policies and procedures and the Ethics Code, psychologists clarify the nature of the conflict, make their ethical commitments known, and to the extent feasible, resolve the conflict consistent with those commitments (Ethics Code, Standard 1.03). Mental Health Act ... long those records need to be kept to meet business needs, accountability requirements and community expectations. They are intended to benefit both the psychologist and the client by facilitating continuity and evaluation of services, preserving the client's privacy, and protecting the psychologist and client in legal and ethical proceedings. Rationale: Psychologists proceed with respect for the rights of individuals to privacy and confidentiality (Ethics Code, Principle E). To the degree that there are conflicts between the institutional policies and procedures and the Ethics Code, psychologists appropriately address these issues as outlined in the Ethics Code (Standard 1.03), clarifying the nature of the conflict, making known their commitment to the Ethics Code, and, to the extent feasible, resolving the conflict in a way that permits adherence to the Ethics Code. The psychologist may consult with colleagues in the organization to support record keeping that serves the needs of different disciplines and while meeting acceptable record keeping requirements and guidelines. The record may potentially include who is responsible for payment, how missed appointments will be handled, acknowledgement of any third-party payer preauthorization requirements, any agreement regarding copayment and adjustments to be made, payment schedule, interest to accrue on unpaid balance, suspension of confidentiality when collection procedures are employed, and the methods by which financial disputes may be resolved (Ethics Code, Standard 6.04). American Psychologist, 57, 1048- 1051. COVID-19 resources for psychologists, health-care workers and the public. 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. This revision of the 1993 "Record Keeping Guidelines" was completed by the Board of Professional Affairs (BPA) Committee on Professional Practice and Standards (COPPS). 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). Psychological practice entails applications in a wide range of settings for a variety of potential clients. Patterson, T. E. (1999). It is helpful to designate the rationale for, description of, and date of any adjustments to the balance that are made as a result of agreement with a third-party payer or the client. The psychologist is often asked to assess or treat individuals who are in crisis or under great external stress. The implication is that each case must be considered individually to determine if there is a reasonable basis for retaining the records longer. Psychologists strive to be aware of the legal and regulatory requirements governing the release of information (e.g., some jurisdictions prohibit the re-release of mental health records, records of sexually transmitted diseases, or chemical dependency treatment records). Determination and documentation of the need for practice guidelines. Disposal of electronic records poses unique challenges because the psychologist may not have the technical expertise to fully delete or erase records, for example, before disposing of a computer hard drive, external back-up storage device, or other repository for electronic records. Knapp, S., & VandeCreek, L. (2003a). ) mental health records refer to just a persons mental health. It is anticipated that psychologists will use their education, skills, and training to identify the relevant issues and attempt to resolve conflicts in a way that conforms to both law and ethical practice. These guidelines do not establish rules for practice, but rather provide an overall conceptual model and strategies for resolving divergent considerations. Emergency or disaster relief settings. To the extent possible, this document attempts to provide guidelines that are generally consistent with these laws and regulations. Barnett, J. E., & Scheetz, K. (2003). Because records may include information about more than one individual client, legitimate disclosure of information regarding one client may compromise the confidentiality of other clients. Up-to-date record keeping can alert the psychologist and the client to accumulating balances that, left unaddressed, may adversely affect the professional relationship. The assurance of confidentiality is critical for the provision of many psychological services. These include details of any treatment you may have been given under the Mental Health Act 1983. How long do you keep my counseling records? For example, an institutional rule for record keeping may prohibit reference to sealed juvenile records or to HIV test results, or a statute may govern disclosure of information about treatment for chemical dependency. American Psychological Association. There are a number of further concerns regarding record keeping with multiple clients. Considerations of record confidentiality are critical when planning for disposal of records. These guidelines are designed to educate psychologists and provide a framework for making decisions regarding professional record keeping. The psychologist is encouraged to carefully weigh these matters in making decisions to retain or dispose of records.7. Clinical Supervisor, 22, 63-80. My Health Record will become an increasingly significant clinical record of an individual’s health and wellbeing. Professional Psychology: Research and Practice, 18, 498-502. The term guidelines refers to statements that suggest or recommend specific professional behavior, endeavors, or conduct for psychologists. Your records will be kept for 20 years after you were last seen or discharged from the Act. Factors associated with technology adoption in private practice settings. McMinn, M. R., Buchanan, T., Ellens, B. M., & Ryan, M. K. (1999). American Psychological Association, Committee on Professional Practice and Standards. 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. (Eds.). Here we set out tables of types of records and the length of time they should be kept. However, in consultative relationships, record ownership and responsibility may be maintained by the psychologist. Records benefit both the client1 and the psychologist through documentation of treatment plans, services provided, and client progress. Answer. It's based on current legal requirements and professional best practice and was published on 20 July 2016 by the Information Governance Alliance (IGA), The record of psychological services may include information of three kinds. In these areas, more aspirational language has been used. This potentially affects the degree to which the psychologist may exercise control of the record and its confidentiality. it is important to note that client records must be kept and maintained in accordance with the state regulations. In some circumstances, the records are the only way that the psychologist or others may know what the psychologist did and the psychologist's rationale for those actions. This code of practice applies to hard copy and digital records, including records of NHS patients treated on behalf of the NHS in the private sector. Psychologists using computers or other digital or electronic storage devices to maintain client treatment records may consider using passwords or encryption to protect confidential material.8 The psychologist strives to become aware of special issues associated with using electronic methods and media and seeks training and consultation when necessary.9. Murphy, M. J. Alteration or destruction of records. For 24/7 emergency COVID advice please call us. In some circumstances, when it is anticipated that the client might want or need to know how records will be maintained, this process may include the disclosure of record keeping procedures. New York: Wiley. For example, a child subjected to severe physical abuse may produce low scores in a cognitive assessment that may not accurately predict the child's future functioning. Koocher, G. P., & Keith-Spiegel, P. (1998). Special consideration may be given to fee agreements and policies, barter agreements, issues relating to adjusting balances, issues concerning copayments, and concerns about collection. Psychologists may plan for archiving of electronic data including file and system backups and off-site storage of data (See Guideline 9). Considerations Regarding the Level of Detail of the Record: A psychologist makes choices about the level of detail in which the case is documented. American Psychological Association, Committee on Legal Issues. Public Record Office Victoria (PROV) has issued over 100 RDAs for use by agencies covered by the Public Records Act 1973. social workers who choose not to keep records risk sanctioning by the state of connecticut, department of public health’s professional licensing division. In the context of litigation, addition or removal of information from a record that has been subpoenaed or requested by court order may create liability for the psychologist. Psychologists using online test administration and scoring systems may consider using a case identification number rather than the client's Social Security number as the record identifier. In contrast, the client may be served by the disposal of the record as soon as allowed. This document aims to elaborate and provide assistance to psychologists as they attempt to establish their own record keeping policies and procedures. Psychologists are urged to organize their records in a manner that facilitates their use by the psychologist and other authorized persons. 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. 20 years after date of last contact between the patient and the mental health provider. In some settings, the physical record of psychological services is owned by the organization and does not travel with the psychologist upon departure. Psychologists should be familiar with legal and ethical requirements for record keeping in their specific professional contexts and jurisdictions. 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. American Psychologist, 57, 1060- 1073. Jerome, L. W., DeLeon, P. H., James, L. C., Folen, R., Earles, J., & Gedney, J. J. Condensed records may be copied and kept in separate locations so as to preserve a copy from natural or other disasters. For example, disaster relief agencies may require only cursory identifying information, the date of service, a brief summary of the service provided, and the provider's name. 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). All records on active clients should be maintained for the duration of the current admission. Based on these findings, BPA directed COPPS to undertake the development of "Record Keeping Guidelines" (APA, Committee on Professional Practice and Standards, 1993), which were subsequently adopted as APA policy. A guide to the 2002 revision of the American Psychological Association's ethics code. For example, a logical file labeling system facilitates the search and recovery of records. Or a psychologist writing a case summary regarding a client who had only been violent in the midst of a psychotic episode is careful to record the context in which the behavior occurred. 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. Identifying data (e.g., name, client ID number); Contact information (e.g., phone number, address, next of kin); Where appropriate, guardianship or conservatorship status; Documentation of informed consent or assent for treatment (Ethics Code, Standard 3.10); Documentation of waivers of confidentiality and authorization or consent for release of information (Ethics Code, Standard 4.05); Documentation of any mandated disclosure of confidential information (e.g., report of child abuse, release secondary to a court order); Presenting complaint, diagnosis, or basis for request for services; Plan for services, updated as appropriate (e.g., treatment plan, supervision plan, intervention schedule, community interventions, consultation contracts); Types of services (e.g., consultation, assessment, treatment, training); Nature of professional intervention or contact (e.g., treatment modalities, referral, letters, e-mail, phone contacts); Formal or informal assessment of client status. 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