Section 13: Maintenance Of Records Flashcards
What does the code state in terms of the length of record retention?
A registrant must ensure that all information in their professional records concerning client is maintained for no less than seven years after the last date that professional services were rendered to the client
What does the code state in terms of maintaining minors records?
A registrant must keep records relating to minors for no less than seven years following the date the minor reached the age of majority. In Canada that is 19 years of age in most provinces. So for most provinces until the age of 26.
What does the code state in terms of legal requirements for maintaining records?
Registration 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 which state no less than seven years after the last date of services with client or no less than seven years, following the date in minor reach the age of majority.
What is the code state in terms of discretion to keep longer?
A registrant must use their judgement in those circumstances in which it may be appropriate to maintain the professional records for longer than seven years
What does the code state in terms of records of equipment maintenance?
A registrant must keep a record of equipment maintenance for all equipment, that if malfunctioning when you used to treat or render any service to clients could cause physical harm to a client
What 10 things must a registrant’s records include when rendering professional services to a client or billing a third-party for professional services?
1) the name of the client and other identifying information
2) the presenting problems, or the purpose of the consultation
3) the fee arrangement
4) the data and substance of each professional service, including relevant information on interventions progress any issues of informed consent, and issues related to termination
5) any test results or other valuated results obtained any basic test data from which of the results were derived
6) a copy of all assessment, or other evaluative reports prepared as part of the professional relationship
7) notations in any results of formal consultations with other service providers
8) any releases, or consents executed by the client
9) copies of any emails or other communications related to the file
10) 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
What must a registrant ensure in terms of complete and legible records?
Ensure that the information in the records under the registration control is complete and accessible. Regardless of whether the records are kept in the single file or in several files, how it one location or at several locations, and regardless of the storage, medium EG paper, electronic combination of paper and electronic.
What 8 things must a registrant with respect to all records, created by the registrant under the supervision of the registrant, in terms of complete and legible records?
1) keep all practice records legible
2) if record is eligible or in a language, other than English, and if requested, so provide a transcript or translation of the record, and an attestation by the registrant, verifying 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 psychologist of British Columbia, a client or another person
3) providing paper copies of electronically or otherwise documents include assigned at test station confirming the paper copies are accurate copies of the original information
4) initial, and all entries in a clinical record
5) initial, and date any amendments or alterations to a clinical record
6) lot of things we do where practice records contain any idiosyncratic or non-standardized abbreviations, provide at the beginning or end of the record, a glossary for the meaning of the non-standard abbreviations
7) number the pages of a practice record at the point the practice record is provided to another person
8) organized the record and a clear and understandable manner, including by date, and/or chronology as appropriate and without unnecessary duplication
What must registration do in terms of 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
What must a registrant do in terms of consent of supervisory records?
A registrant must maintain records of supervise sessions, and include among other information, the type place and general content of the session, including any directions given to the supervisee, must also maintain a supervise record copies of any evaluations or other communications, written, or otherwise provided to others regarding the supervisee
What seven pieces of information must be included in a registrant’s record of fees charge to receive from a client or third-party pair that is made available to client or third-party pair upon request?
1) The service provider
2) the recipient of the professional services
3) the date, nature and unit fee of the service provided
4) the total charged
5) the payment received
6) the date and source of payment
7) any other information that the client may need to obtain insurance reimbursement such as diagnostic codes, length of session, etc.
What is the code state in terms of no basis for disposing of records?
Financial expense or other inconvenience is specifically not sufficient ground for failing to keep copies of all the documents referred to in standard, 13.6, including reports and other documents from other professionals that were relied upon and providing one service or opinion.
What must a registrant document in the event that 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?
A registrant document in the retained portion of the record, the location of the missing foundational records, and must treat all documents as institutional records for purposes of advising a college of all of their practice record locations
