|(a) General Requirements.
(1) All licensees shall create and maintain accurate,
current, and pertinent records of all psychological services rendered
by or under the supervision of the licensee.
(2) All records shall be sufficient to permit planning
for continuity in the event that another care provider takes over
delivery of services to a patient or client for any reason, including
the death, disability or retirement of the licensee and to permit
adequate regulatory and administrative review of the psychological
(3) All licensees shall identify impressions and tentative
conclusions as such in patient or client records.
(4) All records and record entries shall be created
in as timely a manner as possible after the delivery of the specific
services being recorded.
(5) Records shall be maintained and stored in a way
that permits review and duplication.
(6) Licensees working in public school settings shall
comply with all federal and state laws relative to the content, maintenance,
control, access, retention and destruction of psychological and educational
records, test data and test protocols.
(7) Licensees are prohibited from falsifying, altering,
fabricating, or back-dating records and reports.
(b) Maintenance and Control of Records.
(1) Licensees shall maintain records in a manner that
protects the confidentiality of all services delivered by the licensee.
(2) Licensees are responsible for the contents of,
as well as the access, retention, control, maintenance, and destruction
of all records unless stated otherwise by law.
(3) Licensees shall make all reasonable efforts to
protect against the misuse of any record.
(4) Licensees shall maintain control over records to
the extent necessary to ensure compliance with all applicable state
and federal laws.
(5) In situations where it becomes impossible for a
licensee to maintain control over records as required by state or
federal law, the licensee shall make all necessary arrangements for
transfer of the licensee's records to another licensee who will ensure
compliance with state and federal laws concerning records.
(6) The possession, access, retention, control, maintenance,
and destruction of records of psychological services rendered by a
licensee as an employee of or contractor for an agency or organization
remain the responsibility of that agency or organization upon termination
of the licensee's employment or contract unless otherwise required
by state or federal law or legal agreement.
(c) Access to Records.
(1) Records shall be entered, organized and maintained
in a manner that facilitates their use by all authorized persons.
(2) Records may be maintained in any media that ensure
confidentiality and durability.
(3) A licensee shall release information about a patient
or client only upon written authorization from the patient or client,
or as otherwise permitted or required under state or federal law.
(4) Test materials are not part of a patient's or client's
record and may not be copied or distributed unless otherwise permitted
or required under state or federal law.
(5) Test data are part of a patient's records and must
be released to the patient as part of the patient's records. In the
event test data are commingled with test materials, licensees may
inquire whether the patient will accept a summary or narrative of
the test data in lieu of having to either redact the test materials
or extract the test data from test materials in order to comply with
the request for records.
(6) Licensees cooperate in the continuity of care of
patients and clients by providing appropriate information to succeeding
qualified service providers as permitted by applicable Council rule
and state and federal law.
(7) Licensees who are temporarily or permanently unable
to practice psychology shall implement a system that enables their
records to be accessed in compliance with applicable Council rules
and state and federal law.
(8) Access to records may not be withheld due to an
outstanding balance owed by a client for psychological services provided
prior to the patient's request for records. However, licensees may
impose a reasonable fee for review and/or reproduction of records
and are not required to permit examination until such fee is paid,
unless there is a medical emergency or the records are to be used
in support of an application for disability benefits.
(9) No later than 15 days after receiving a written
request from a patient to examine or copy all or part of the patient's
mental health records, a psychologist shall:
(A) make the information available for examination
during regular business hours and provide a copy to the patient, if
(B) inform the patient in writing that the information
does not exist or cannot be found; or
(C) when withholding information, provide the patient
with a signed and dated statement reflecting the licensee's determination,
based upon the exercise of professional judgment, that the access
requested is reasonably likely to endanger the life or physical safety
of the patient or another person. The written statement must specify
the portion of the record being withheld, the reason for denial and
the duration of the denial.
(10) A licensee may, but is not required to provide
a patient with access to psychotherapy notes, as that term is specifically
defined in 45 C.F.R. §164.501, maintained by the licensee concerning
(d) Retention of Records.
(1) Licensees shall comply with all applicable laws,
rules and regulations concerning record retention.
(2) In the absence of applicable state and federal
laws, rules and regulations, records and test data shall be maintained
for a minimum of seven years after the date of termination of services
with the patient, client, or subject of evaluation, or five years
after a patient or subject of evaluation reaches the age of majority,
whichever is greater.
(3) All records shall be maintained in a manner which
permits timely retrieval and production.
(e) Outdated Records.
(1) Licensees take reasonable steps when disclosing
records to note information that is outdated.
(2) Disposal of records shall be done in an appropriate
manner that ensures confidentiality of the records in compliance with
applicable Council rules and state and federal laws.