The American Psychological Association (APA) has an online guide to record keeping for psychologists. Of the different mental health disciplines, the APA’s guidelines are the most extensive. For the full guide (and tons of fun), go to: http://www.apa.org/practice/guidelines/record-keeping.aspx. A brief summary of the guide follows.
As an introduction, the APA emphasizes that clinical records are beneficial for clients and practitioners. When done well, clinical records can:
1. Document that planning has occurred
2. Guide treatment services.
3. Allow providers to review and monitor their work.
4. Enhance continuity when there are treatment breaks or referrals to other providers.
5. Protect clients and providers during legal or ethical proceedings.
6. Fulfill insurance or third-party reimbursement requirements.
The APA’s document is a guide and not a mandate. It’s designed as aspirational. APA also notes that there’s no significant empirical research foundation upon which their guidelines are based. Instead, the guidelines are broadly based on APA policy, professional consensus, and other sources of ethics and legal information.
The following list paraphrases and summarizes APA’s 13 guidelines. There’s always the possibility that our list and descriptions include minor mistranslations. Consequently, please see the full document for comprehensive coverage of this important content.
1. Responsibility: Practitioners are responsible for the development and maintenance of their clinical records. This includes training staff in the appropriate confidential handling of client records.
2. Record Content: Records include information about the nature, delivery, treatment progress and outcomes, and fees. Information included is directly relevant to the clinical purpose of client contacts. Although detail is important, the following factors guide the level of details included in individual client case files:
a. Clients’ wishes
b. Disaster or emergency settings
c. Ethical or legal limitations (e.g., HIV testing results)
d. Contracts with third party payers
e. The APA guide includes extensive information regarding what content may or may not be appropriate.
3. Confidentiality: Maintenance of confidentiality is essential. In situations where who has access to records may be unclear (e.g., child custody conflicts), the provider seeks pertinent legal information to guide decision-making.
4. Informed Consent: Practitioners provide clients with information regarding their record keeping procedures, including limits to confidentiality.
5. Records Maintenance: Records are organized to comply with federal law (HIPAA) and accuracy is maintained.
6. Records Security: Records are kept safe from physical damage. Access to records is controlled via a variety of methods, including locked cabinets, locked storage rooms, passwords, data encryption, etc.).
7. Records Retention: Records are retained for a time period consistent with legal requirements. The general guide is seven years after service ended for adults and three years after a minor reaches age 18 (whichever is later).
8. Records Context: Because client symptoms or condition can vary with situational contexts, providers frame the content of client records within the appropriate historical context.
9. Electronic Records: Electronic records use and storage presents ongoing challenges. The best guidance is for practitioners to follow the HIPAA Security Rule, conduct a security analysis, and consistently upgrade policies and practices to keep up with changes in technology.
10. Records within Agencies: Practitioners must balance their professional ethical requirements and agency policy. The APA identifies three main areas: (a) conflicts between the agency and other requirements, (b) records ownership, and (c) records access.
11. Multiple Client Records: When providing couple, family, or group services, records management may become complex. You can consider either creating separate records for all clients or to identify a primary client and keep records for that person.
12. Financial Records: The nature of the fee agreement (including bartering agreements) as well as adjustments to account balances should be specified. Financial records include essential information such as procedure codes, treatment duration, fees paid, fee agreements, dates of service, etc.
13. Records Disposition: In the case of unexpected events, there may be a need for records transfer or disposal. This implies a need for a records transfer and disposal policy, including information on how current and former clients will be informed if the policy needs to be enacted.
The APA guide is a comprehensive document that can help all practicing clinicians maintain high ethical standards with respect to documentation.