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.

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