Recordkeeping

The Rules of the Board of Regents on Unprofessional Conduct, ยง29.2(a)(3) require that health professionals maintain records for each patient that accurately reflects the evaluation and treatment of the patient. Records for children from birth to age 21 should be maintained for six years and for one year past age 21. These records serve more than one purpose:

  • Consumer Protection
  • Professional Purposes
  • Professional Assistance
  • Business Record
  • Professional Liability

Practitioners and their patients should be aware that under some conditions other persons might have access to the records. Your records, therefore, should be an accurate and legible account of the evaluation and treatment of the patient.

Under Section 18 of the Public Health Law, patients have the right of access to their records under most circumstances. If you deny access to records to a patient, you have an obligation to inform the patient of his/her right to appeal to the Office of Record Access of the Department of Health.

If you dispose of records when there is no obligation or need to maintain them, they should be properly destroyed to safeguard patient confidentiality.

Psychologists who retire or sell their practice must make provision for records to be maintained and accessed, if requested. The obligation to maintain records is not changed by the retirement or sale of practice by a psychologist.

The records of patients may not be included in the sale of a professional practice without the specific, informed consent of the patient. Names and other personal information about patients may not be identified in the course of a sale of a practice or in the assessment of the value of a practice.

Your records may be your principal defense in charges of professional misconduct. There is no statute of limitations for charges of professional misconduct.

Additionally, psychologists should also make provision for the maintenance and destruction of their patients' records in the event of the psychologist's death. While professional misconduct charges would not be brought after the death of a psychologist, the psychologist's estate could be the focus of a malpractice suit.

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Last Updated: June 11, 2009