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. Records on clients who have been discharged from the program or who died while receiving services from the program should be retained for seven years from the date services are terminated or, if the client died, seven years from the date of the death. Methods reflecting consistency and logic are likely to be most useful. Knapp, S. J., & VandeCreek, L. D. (2006). Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Jacovino, L. (2004). Those may include such factors as improved opportunities for the treatment provider to identify trends or patterns in the therapeutic interaction, enhanced capacity to reconstruct the details of treatment for litigation purposes, and more effective opportunities to use supervision and consultation. They discuss special situations: electronic records, organizational settings, and multiple clients. 20 years or 8 years after the patient has died. 111-128). The record of psychological services may include information of three kinds. American Psychological Association Practice Organization. The psychologist is guided by the Ethics Code (providing that psychologists may disclose information to a legally authorized person on behalf of the client/patient unless prohibited by law; Ethics Code, Standard 4.05) as well as by state and federal regulations in these matters. 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. Minnesota’s Health Records Act gives patients broader rights when it comes to accessing mental health records because it does not distinguish psychotherapy notes from other medical records Minnesota law requires that a provider give a patient “complete and current” information concerning any diagnosis, treatment or prognosis that relates to the patient upon request (Minn. Stat. Where standards and legal and regulatory codes exist, they take precedence over these guidelines. Record keeping procedures are directed, to some extent, by the Ethics Code and legal and regulatory requirements. Additionally, the Ethics Code (Standards 6.01 and 6.02) requires psychologists to dispose of records in a way that preserves their confidentiality. Rationale: The usefulness of psychological service records often depends on the records being systematically updated and logically organized. (2003). The psychologist strives to create and maintain records in such a way as to preserve relevant information about the context in which the records were created. The following issues may provide a guide to assist the psychologist in wrestling with these tensions: The client's wishes. They are not definitive and they are not intended to take precedence over the judgment of psychologists. Guidelines are not intended to be mandatory or exhaustive and may not be applicable to every professional situation. The problem is that a persons address and personal details are included in such records, so if the records were public (the alternitive to them being private), then it would be easier for people with malicous intentions to do whatever they want. When that context changes over time, the relevance and meaning of the information may also change. Professional Psychology: Research and Practice, 37, 215-222. Ethical principles of psychologists and code of conduct. Observations on the retirement of professional psychologists. 25 years after the birth of the last child. Preserving the context of the record protects the client from the misuse or misinterpretation of those data in a way that could prejudice or harm the client. Considerations of record confidentiality are critical when planning for disposal of records. Computer technology for office-based psychological practice: Applications and factors affecting adoption. The requirement represents a minimum requirement for the length of time psychologists must retain mental health records. Ethics in psychology: Professional standards and cases. Ethical and legal issues in professional practice transitions. American Psychologist, 55, 407-421. In contrast, the client may be served by the disposal of the record as soon as allowed. U.S. Department of Health and Human Services, Office for Civil Rights. These guidelines are scheduled to expire 10 years from February 16, 2007 (the date of adoption by the APA Council of Representatives). The paper office (3rd ed.). 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. Here we set out tables of types of records and the length of time they should be kept. 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. (2002). A fee agreement or policy, although not explicitly required for many kinds of psychological services such as preemployment screening under agency contract or emergency counseling services at a disaster site, provides a useful starting point in most service delivery contexts for documenting reimbursement of services. 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. Where appropriate, a psychologist maintains control over clients' records, in accordance with the policies of the institution in which psychological services are provided and consistent with Ethics Code, Standard 6.01. (2006). After drafting a proposed revision, COPPS sought feedback and incorporated suggestions from the APA Ethics and Legal offices. The use of email in a child and adolescent mental health service: Are staff ready? Alteration or destruction of records. Adjustments to balance. This might include, among other things, behavioral ratings or logs, diaries, journals, letters from the client's children, pictures or videos, or greeting cards. Often, multiple service providers access and contribute to the record. Intermediate care facilities must keep medical records for at least as long as the resident remains at the facility and five years thereafter, or in the case of a minor, five years after the resident reaches the age of majority. These guidelines are intended to assist psychologists in making such decisions. Although the HIPAA privacy rule generally requires that health care providers obtain patient consent prior to releasing identifiable health care information, there is an exemption when the Board requests medical records from physicians. For example, in transporting records to be shredded, the psychologist may take care that confidentiality of the records is maintained. Washington, DC: American Psychological Association. Comments and recommendations were incorporated by COPPS, and a revised draft was submitted to BPA on November 9, 2006. Conducting that risk analysis may be advisable even for psychologists who are not technically subject to HIPAA. These "Record Keeping Guidelines" provide a framework for keeping, maintaining, and providing for the disposition of records and what is contained in them. The psychologist working in these settings is encouraged to be sensitive to this wider access to the information and to record only information congruent with organizational requirements and necessary to accurately portray the services provided. COPPS also considered the implications of current federal and state laws and regulations, including HIPAA. … Answer. This includes prisoners transferred to hospital for treatment under the Mental Health Act. BPA reviewed and approved the draft for release for a Call for Comments. Couple and family documentation sourcebook. Ten interdisciplinary principles for professional practice in telehealth: Implications for psychology. 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. In Practical ethics for psychologists: A positive approach (pp. Are mental health records confidential? Zuckerman, E. (2003). There are a number of further concerns regarding record keeping with multiple clients. Independent Practitioner, 23, 72-76. A specific area of concern is the re-release of data that have been included in the client's record. A call for comments was published in the APA Monitor and circulated to state, provincial, and territorial psychological associations and to APA divisions. Psychotherapy: Theory, Research, Practice, Training, 40, 86-93. Professional Psychology: Research and Practice, 34, 388-395. 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. 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). Psychologists should be familiar with legal and ethical requirements for record keeping in their specific professional contexts and jurisdictions. For example, children in treatment following marital dissolution may be brought for services by one parent who wishes the record to be kept confidential from the other parent, or an adolescent who is near but has not quite reached the age of majority may request that records be kept confidential from the parent/guardian. This is not an exhaustive list of sources that psychologists may find useful in determining the best course of action in record keeping, and it is not intended to be representative of the entire body of knowledge that can guide decision making. Determination and documentation of the need for practice guidelines. The psychologist considers whether the decision to maintain less detailed records deviates from contracts between the psychologist and third-party payers. 10 years after the last discharge, but master patient index data must be kept permanently. National Insurance number 7. date present employment started Recorded details of each health surveillance check should include: 1. the date they were carried out and by who… Region: Ontario Answer # 707. 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. Professional Psychology: Research and Practice, 34, 309-311. 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. COPPS is grateful for the support and guidance of the BPA, particularly to BPA Chairs Kristin A. Hancock (2006), Rosie Phillips Bingham (2005), and Jalie A. Tucker (2004). Recommendations for risk-management practices. In some situations, one set of considerations may suggest a different course of action than another, and it is up to the psychologist to balance them appropriately. American Psychological Association. This will vary depending upon practical concerns, ethical guidelines, and third-party reporting requirements. Benefield, H., Ashkanazi, G., & Rozensky, R. H. (2006). This may reduce potential misunderstanding or perceived obligations that might affect the relationship. In some circumstances, the psychologist may consider a method for notifying clients about changes in the custody of their records. Often, rules for record creation and maintenance reflect requirements of all relevant disciplines, not only those related to psychological services. Top Answer. Correspondence concerning this article should be addressed to the Practice Directorate, American Psychological Association, 750 First Street, NE, Washington, DC 20002-4242. Technological advances and telehealth: Ethics, law, and the practice of psychotherapy. In this situation, if permitted by institutional rules and legal and regulatory requirements, the psychologist may keep more sensitive information, such as therapy notes, in a separate and confidential file.10. In these areas, more aspirational language has been used. Strategies for private practitioners coping with subpoenas or compelled testimony for client records or test data. The psychologist takes into account the statutes and regulations that govern practice and heeds mandates in making decisions about record detail. Retrieved December 9, 2006. Halloway, J. D. (2003). Rules and Regs. Specific state and federal laws and regulations govern psychological record keeping. In making decisions about the content of records, the psychologist takes into account factors such as the nature of the psychological services, the source of the information recorded, the intended use of the records, and his or her professional obligations. The manner in which records are maintained may potentially affect the client in ways that may be unanticipated by the client. 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. Develop-Ments, BPA directed copps to revise the `` record keeping guidelines were examined to ensure internal consistency of policies. Concerns regarding record keeping with multiple clients an overview of the key principles of the last discharge, rather. 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