Disclaimer: Law, rules and regulations, not Guidelines, specify the requirements for practice and violating them constitutes professional misconduct. Not adhering to this Guideline may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations.
Recordkeeping
The Rules of the Board of Regents on Unprofessional Conduct require that health professionals complete and maintain accurate records for each patient. These records include referral orders for evaluation and treatment, including specific treatment protocols, and documentation of findings from evaluation, treatment, patient response, and recommendations. Records must be maintained for six years and for one year past age 21 for patients from birth to 21 years of age.
Professionals and their patients should be aware that under certain conditions other individuals might have access to patient records. Practitioners must request patients' release of information prior to transmitting records to other individuals, institutions, or third party payers, except as authorized by law. Records must be maintained in a manner to assure patient confidentiality. Your records must be accurate, legible, and signed with appropriate identifying credentials.
Under Part 29 of the Regents Rules, patients have the right of access to records which have been prepared for and paid for by the patient or client. If you deny access to records to a patient, you must inform the patient of his/her right to appeal to the Office of Record Access of the Department of Health.
Audiologists and speech-language pathologists who maintain electronic records should implement a mechanism of safeguarding and maintaining records and confidentiality in the event of an electronic failure.
If you dispose of records when there is no obligation or need to maintain them, they must be properly destroyed to safeguard patient confidentiality.
Professionals who retire or leave their practice must make provision for records to be maintained and accessed, if requested. The obligation to maintain records is not changed by retirement or leaving the practice.
The records of patients may not be included in the sale of the assets of a professional practice, except as authorized or required by law. Patient names and other personal information may not be identified in the course of a sale of the assets of a practice or in the assessment of the value of professional assets.
Records may be your principal defense in charges of professional misconduct. There is no statute of limitation for charges of professional misconduct.
Professionals should make provisions for the maintenance and destruction of patient records in the event of the therapist's death. While professional misconduct charges may not be brought against an audiologist or SLP after his/her death, the therapist's business entity or estate could face a need for the adequate maintenance of those records.