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November 2011

Disciplinary Actions

Professional Record Keeping: Part I Salvatore Cullari, Ph.D., Vice Chairman Alex M. Siegel, J.D., Ph.D., Former Board Chairman Over the next few quarters, the State Board of Psychology will provide you with a series of articles related to keeping and maintaining records for your practice. Aside from assessment and treatment, record keeping is the third most critical aspect of providing effective psychological services. In fact, at the basic level, providing psychological services forms the trilogy of assessment, treatment and record keeping. In addition to helping you provide the optimal level of care for the client by monitoring progress, record keeping insures that if a legal or ethical complaint is filed against you, there will be clear evidence of what, where, when and in what context services were provided. Records can help protect both you and your client in this event or if there are any billing questions from third party payees. In order to be valuable, records must be accurate, detailed and current. Records that are written in vague or broad terms may not be useful in the event of any type of investigation, or even for your own use. Also, a factor that is often neglected is providing a rationale for your actions. It is difficult or impossible to second guess why you took the actions that you did after the fact. Remember, if its not written down, it did not occur (or at least you cannot prove that it did occur). Also, not having any notes or records is NOT an option for licensed psychologists.

What records do you need to keep? The style and extent of records will vary depending on the type and setting of the psychological services that are provided. Under 41.57 of the Boards regulations (commonly known as the Green Book), the MINIMUM requirements of record keeping are listed. These include the name and address of the client; the presenting problem or diagnosis; the fee arrangement; the date and substance of each formal client contact; details of any assessment or test results, including a copy of any test or evaluation report; notation and results of formal consults with other providers; and all authorizations by the client for release of records or other information. If the client is a minor, the names of the parents or legal guardians are required. If the parents are separated, the legal custodial arrangements must be listed. Note that the provider must also comply with any other state or federal record keeping requirements that are more stringent than those above. These may be different depending on the age of the client, the agency that is involved or the types of services provided (e.g., Medicare, HIPAA, child abuse reporting, etc.). Adequate records are also typically a requirement for third-party reimbursement, and these standards may vary as well. Lastly, the American Psychological Association has developed guidelines for record keeping, and licensed psychologists should be well-versed with all of these standards. It is incumbent on the psychologist to start keeping records at the beginning of the therapeutic relationship and include all relevant information into the record. For example, if your clients call to set up an appointment you might not need to document that call. However, if the client tells you why they are calling and you engage the
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Pennsylvania State Board of Psychology www.dos.state.pa.us November 2011

Page | 2 Disciplinary Actions

client over the phone, then it should be part of the record. The same is true about email. If a client emails you to set up an appointment or cancel one that probably does not have to be part of the record. However, any email that is substantive should be printed and made part of the record. If you have any doubt, then document. Your records should document the course of treatment, client progress or lack of progress, and all types of services rendered. The Board does not mandate a certain style (i.e., Process, SOAP or DAP note) but each entry must record the substance of each contact. If something is not written down, it is very difficult to prove it happened. For example, in a worst case scenario, if a client commits suicide and the family sues you for malpractice or files a licensing board compliant against you and there are no notes, it is very difficult to prove what actions you took to try to prevent the suicide. If you document what steps you took to help the client, (i.e. discuss hospitalization or more frequent sessions) then the records will speak for themselves. In a similar vein, any type of serious risk factor associated with the client (suicide/homicide, psychosis, etc.) should be well documented. Section 41.57(d) of the Boards regulations indicates a psychologist shall assure that all data entries in professional records are maintained for at least 5 years after the last date that service was rendered. Longer periods may be required by other state or federal agencies. In addition, records should be kept in a secure place and in a manner

that ensures confidentiality. If you use electronic means to gather information, then records must be backed up and you should use some type of encryption to prevent hacking, as well as strong passwords, firewalls and other security measures. In any situation where records may be accessed by anyone other than the licensed psychologist, such as office staff, procedures must be developed, written down and maintained in order to protect the confidentiality of the information. Access to records should be limited only to appropriately trained staff, and then only on a limited need to access basis. New staff persons should be trained before having access to any records. Section 41.57(e) of the Boards regulations states a psychologist shall provide for the confidential disposition of records in the event of the psychologists withdraw from practice, incapacity or death. Psychologist need to make arrangements for the records before any of the above happens. One way to accomplish this is by making a codicil to your will explaining what happens to your records. Another way is to confidentially discuss with a colleague if they would be willing to manage your records after your withdrawal from practice. An added benefit of adequate record keeping is that the person who assumes your role will have a detailed account of what has transpired in the past with this particular person. Part II will look at some other features of professional record keeping.

Contact Us

Report Unethical Activity

Renew Your License

Meet the Board

PHMP
(717) 783-7155

State Board of Psychology

P.O. Box 2649, Harrisburg, PA 17105-2649