This document discusses guidelines and requirements for maintaining professional records. It notes that psychologists must keep private all client records, including for couples and families. Records must be kept for a minimum of 7 years after services end for adults or until the client reaches the age of majority. Personal notes are exempt from subpoenas and can be disposed of at any time. Records containing forensic or legal information have additional requirements to be used appropriately in legal matters. The document also discusses secure storage, transmission, and disposal of confidential records.

1. Kayla S. Bordelon
PSYC 3800

2.  6.01 Documentation of
Professional and Scientific
Work and Maintenance of
Records
 6.02 Maintenance,
Dissemination, and
Disposal of Confidential
Records of Professional and
Scientific Work
 6.03 Withholding Records
for Nonpayment

4.  Multiple Client Records  A) family unit or each
individual
When providing for couples or
families, professionals must  B) legal requirements
keep private all records.
Access to files include:
 C) Agreement on the record
keeping policy

5.  Along with state,  7 years after the
federal, and certain last date of service
institution for an adult or until
requirements, 3 years after minor
records are to be reaches age of
maintained for a majority.
minimum time..

6.  Personal notes  HIPPA creates a category for
personal notes.
 Exempt from subpeonas
 Personal notes are exempt
 Can be disposed of at any from HIPPA billing,
time payments, or other
operations.

7.  Records should include
documentation of billing
agreement.
 Barter agreements and
transactions
 Document and justify any
adjustment in balance owed
 Fee collections recorded

8.  Organizations have their
own record keeping
requirements
 Record organization is set
by relationship with the
organization and the
professional
 Multiple staff members
have access and contribute

9.  Forensic records must be created and
maintained to be used appropriately in legal
matters
 All records used for a case is subject for
discovery

10.  Records must be maintained
in order for replication
 Federal regulations state
records should be
maintained for 3 years
 Federally funded grants must
maintain a record of
participant compensation,
assistant salaries, equipment,
travel, balances, and time
and effort reporting

12.  Required when information is  Protected passwords, de-identify
transmitted in electronic form information
for
 Health care claims, health plan
premium payments, referral
certification, injury reports, and
transfer of records to other
professionals
 Professionals must keep doors
locked and must store
information to where guests are
unlikely to see
 Terminated employees do not
have access to any information

13. Physical records may belong
to organization and can not
leave premise.
Advanced planning is needed
for secure transfer of such
records in case of planned or
unplanned events
Psychologist transferring
forensically relevant records
should be familiar with any
laws

15.  Under the Ethics Code,
psychologist are not
required to obtain the
clients consent to release
information due to an
emergency
 HIPAA permits disclosure
also without having
informed consent by patient

16.  All records must be under
the psychologist’s control
 The records must also be
requested

17.  HIPAA Privacy Rule does not
distinguish between
emergency and
nonemergency requests
 HMO contracts with
psychologists

18.  Fisher, C. (2013). Decoding the ethics code: A
practical guide for psychologist. (3 ed., pp.
178-190). Los Angelos: SAGE.