Recordkeeping Guidelines for Psychologists

Rationale: Consumers, psychologists, educators, and students have continually sought the opinion of the Department as to what constitutes a record in the practice of psychology. Even among persons noted for their knowledge of what constitutes ethical practice or a sound standard of practice, there has been disagreement regarding what is necessary for the maintenance of records to comply with Section 29.2(a)(3) of the Rules of the Board of Regents on Unprofessional Conduct:

"Failing to maintain a record for each patient which accurately reflects the evaluation and treatment of the patient. Unless otherwise provided by law, all patient records must be retained for at least six years. Obstetrical records and records of minor patients must be retained for at least six years, and until one year after the minor patient reaches the age of 21 years."

The Board for Psychology has determined that the development of a recordkeeping guideline would serve the following purposes:

  1. Consumer Protection
    1. Assurance of compliance with the general requirements of business law and insurance law;
    2. Availability of a record of the client/patient's psychological history and treatment for personal use, for forensic use, and for appropriate ongoing treatment;
    3. Maintenance of a record for the client/patient's use for insurance reimbursement and other health-related claims, e.g., workers' compensation.
  2. Professional Purposes
    1. Assistance with ongoing therapy;
    2. Assistance for other professionals where appropriate;
    3. Maintenance of information needed for insurance purposes.
  3. Professional Assistance
    1. Assistance in legal proceedings;
    2. Assistance in comparing similar cases and assessing treatment approaches;
    3. Memory refreshment tool for professional use.

Caveat: In establishing records, psychologists should be familiar with and observe all other state laws, regulations, and codes which apply. These include, but are not limited to:

  1. The Public Health Law
  2. The Mental Hygiene Law
  3. The Administrative Procedures Law
  4. The Education Law
  5. The Social Services Law

and the regulations of those agencies which implement these laws through regulations. In preparing the Guideline, the Board has recommended what they consider to be the essential content of a usual client/patient record. In addition, the Board recommends that these guidelines be modified based on professional ethical standards for those non-direct human service providers, e.g., industrial/organizational psychologists, research psychologists, etc.

The client/patient record should include:

  1. Name
  2. Address
  3. Home and office telephone numbers
  4. Date of first contact with the client/patient and nature of contact
  5. Demographic data, gender, age
  6. An accurate record of the evaluation and treatment of the client/patient and any significant changes of treatment over the course of service
  7. Documents, such as contracts and consent forms
  8. The date and nature of each billed service contact
  9. Names of individuals with whom the psychologist formally consulted about the client, including reasons for consultation, dates and relevant consent forms
  10. A copy of all test or other evaluation reports prepared as a part of the professional relationship
  11. Narrative of all significant outside billable contacts between the psychologist and others
  12. Billing and payment history, including insurance payment
The ongoing record should also include, as appropriate and relevant:
  1. Referral source, if any
  2. Family data (marital status, children, custodial and other information, if pertinent)
  3. Special information or conditions that might have an impact on treatment or cause the patient/client stress, e.g., sensory impairment, socioeconomic status, physical impairment or other special circumstances
  4. Observations about the individual's language facility if relevant (e.g., the client does not speak English, cannot read, etc.)
  5. Medical/psychiatric history (pertinent illnesses and treatment)
  6. History of substance use, including use of prescription medications (with dosages), current medications taken, use of over-the-counter drugs, patterns of abuse, and history of current treatment received
  7. Use of alcohol and nature of use; patterns of abuse and history of treatment received
  8. Name of the client's personal physician, if known
  9. Telephone number of someone to contact should an emergency incapacitate the client
Last Updated: June 11, 2009