How long are psychological records kept

Psychologists have long faced the tension between keeping minimal or detailed records of therapy. Minimal or lean records are more protective of patient privacy if the records are sought by insurers or other third parties, such as attorneys. Detailed therapy records, on the other hand, can facilitate continuity of care if the patient must transfer to another psychologist, can remind the psychologist of details that may be important later in therapy, and may assist the psychologist in the event of a licensure complaint or lawsuit.

For example, a lean record might indicate that the psychologist is working with the patient on interpersonal issues at work complicated by his diagnosis. A very detailed record might document that the patient is having trouble being sexually intimate with his partner and is instead compulsively watching pornography at work due to continued distress related to childhood sexual abuse. Psychologists with patients who obtain coverage through insurance exchanges are most likely to experience these audits, and it appears that those with Medicare Advantage clients may face very similar audits.

While we do not yet know whether insurance carriers outside of the exchanges will be conducting similar audits, we can expect that more psychologists will receive audit requests once the practice begins in As explained in a prior PracticeUpdate article , the APA Practice Office of Legal and Regulatory Affairs recommends that psychologists who anticipate receiving these audit requests either keep a lean clinical record or, if they want to record sensitive details, keep separate psychotherapy notes, as defined by the Health Insurance Portability and Accountability Act HIPAA.

For psychologists who want or need more detail, keeping separate psychotherapy notes allows them to record sensitive information and other particulars from therapy while protecting this information from third parties.

This practice also creates a separate clinical record PDF, KB that is more appropriate for, and easier to share with, insurers and other health care providers. Underlying this recommendation is the threshold question: Do you want detailed therapy notes in the first place?

This article briefly touches on some considerations to help you answer that question. What does an ideal patient record look like? There is no such thing as an ideal patient record and therefore no answer to this question. However, guidance is available from a number of sources that can help you decide how to document your interactions in a manner that fits your style often influenced by experience and training while protecting patient information.

This ensures accurate recall, especially when clients are seen back-to-back in a busy practice. Finally, psychologists should maintain complete records of psychological services in sufficient detail to permit planning for continuity in the delivery of services. This does not mean that every word and action that occurs in an episode of service needs to be recorded. Unnecessary and irrelevant detail should not be included.

However, as a guide, when the Council audits client records, there is an expectation that the following will be present:. In summary, when considering how much detail to include in the record, ensure that the notes are sufficiently comprehensive and accurate to allow another psychologist to read the records and continue to provide service. Client records - why they matter Simon Milton - Professional Officer. The initial client record following an assessment should include : Presenting complaint, diagnosis or basis for request for services History of presenting complaint including response to previous interventions, as well as any relevant history e.

Each subsequent substantive contact with a client should include : Date of service and duration of session Type of service provided e. References American Psychological Association Record keeping guidelines. Maintain all paper and electronic patient records in a secure area accessible only to authorized persons in accordance with applicable State and federal laws and regulations and in a manner that lends itself to substantiating the records to be trustworthy and unalterable.

Be aware of retention requirements for patient records, including the period you are required to retain records by law. You should plan to retain records for a longer period, when necessary, such as a patient with a long-term condition whose treatment will continue beyond the statutory requirement. You must keep records for 6 years or until the patient turns 22 years of age, which ever is longer.

You should be familiar with requirements for providing patient access to records.