13.0 MAINTENANCE OF RECORDS Flashcards
13.1 Length of record retention
A registrant must ensure that all information in their professional records concerning a client is maintained for not less than seven years after the last date that professional services were rendered to that client.
13.2 Minors’ records
A registrant must keep records relating to minors for not less than seven years following the date the minor reached the age of majority.
13.3 Legal requirements
A registrant must comply with all legal requirements for record retention, including maintaining records for a longer period than that required in Standards 13.1 and 13.2 where legally required to do so.
13.4 Discretion to keep longer
A registrant must use their judgment in those circumstances in which it may be appropriate to maintain their professional records for longer than seven years.
13.5 Records of equipment maintenance
A registrant must keep a record of equipment maintenance for all equipment that, if malfunctioning when used to examine, treat, or render any service to clients, could cause physical harm to a client.
13.6 Content of records
A registrant rendering professional services to a client or billing a third party for professional services must maintain records that include the following:
a) the name of the client and other identifying information;
b) the presenting problem(s) or the purpose of the consultation;
c) the fee arrangement;
d) the date and substance of each professional service, including relevant information on interventions, progress, any issues of informed consent, and issues related to termination;
e) any test results or other evaluative results obtained and any basic test data from which the results were derived;
f) a copy of all assessment or other evaluative reports prepared as part of the professional relationship;
g) notations and any results of formal consultations with other service providers;
h) any releases or consents executed by the client;
i) copies of any emails or other communications related to the file; and
j) a copy of all documents relied upon in the course of providing psychological services, including but not limited to reports, evaluations, and test results generated by other health professionals.
13.7 Complete and legible records
(1) A registrant must ensure that the information in the records under the registrant’s control, required in Standard 13.6, is complete and accessible,
regardless of whether the records are kept in a single file or in several files, housed at one location or at several locations, and regardless of the storage medium (e.g., paper, electronic, combination of paper and electronic).
(2) A registrant must, with respect to all records created by or under the supervision of the registrant:
a) keep all practice records legible;
b) if a record is illegible or in a language other than English and if requested to do so, provide a transcript or translation of the record, and an attestation by the registrant verifying the accuracy of the transcript or translation, when the record is to be copied or
transferred as part of a legitimate request by the College of Psychologists of British Columbia, a client, or another person;
c) if providing paper copies of electronically or otherwise stored documents, include a signed attestation confirming the paper copies are accurate copies of the original information;
d) initial and date all entries in a clinical record;
e) initial and date any amendments or alterations to a clinical record;
f) where practice records contain any idiosyncratic or non-standard abbreviations, provide, at the beginning or end of the record, a glossary for the meanings of the non-standard abbreviations;
g) paginate a practice record at the point the practice record is provided to another person; and
h) organize the record in a clear and understandable manner, including by date and/or chronology, as appropriate, and without unnecessary duplication.
13.8 Supervisory records
A registrant must maintain records regarding the supervision of an individual for a minimum of seven years after the last date the registrant provided supervisory services related to that individual.
13.9 Content of supervisory records
A registrant must maintain records of supervised sessions that include, among other information, the type, place, and general content of the session, including any directions given to the supervisee. A registrant must also maintain in a supervisee’s record copies of any evaluations or other
communications, written or otherwise, provided to others regarding the supervisee.
13.10 Record of fees
A registrant must maintain a record of fees charged to and received from a client or third party payer, and make it available to a client or third party payer
upon request. The record must contain the following information:
a) the service provider;
b) the recipient of the professional services;
c) the date, nature, and unit fee of the service provided;
d) the total charged;
e) the payment received;
f) the date and source of payment; and
g) any other information that the client may need to obtain insurance reimbursement, such as diagnostic codes, length of session, etc.
13.11 No basis for disposing of records
Financial expense or other inconvenience is specifically not sufficient grounds for failing to keep copies of all documents referred to in Standard 13.6, including reports and other documents from other professionals that were relied upon in providing one’s service or opinion.
13.12 Documents held in an institution
In the event a registrant is prevented by legal or contractual circumstances from keeping copies of documents which they relied upon and the documents
are held by an institution, the registrant must document in the retained portion of the record the location of the missing foundational records, and must treat the documents as institutional records for purposes of advising the College of all of their practice record locations
