If all documents in a customer record are prior to the minimum retention period, the customer records may be destroyed. In deciding on the content of records, psychologists consider factors such as the nature of the psychological services, the source of the information recorded, the intended use of the records, and their professional obligations. Some hospitals, clinics, prisons or research institutions prescribe the recording format, the specific data to be collected and recorded, and the timeframes within which records must be created. A psychologist strives to include only information relating to the objectives of the service provided (Code of Ethics, Standard 4.04). In addition, in accordance with the Code of Ethics (Principle A), psychologists are sensitive to the possible effects of the language used in the recording (e.B. pejorative terms, pathologizing language) on the client. Typically, there are several essential elements to ensure compliance during storage. Be sure to store them with fire systems and keep records safe when left unattended. To ensure the integrity and availability of customer records in electronic storage systems, you need disaster recovery and business continuity plans. These plans should include securing clients` electronic records. This can be an internal or external backup. Both systems must have guarantees at least equivalent to the production storage system and limit access to those who need it. Psychological practice involves applications in a variety of environments for a variety of potential clients.
This document has been written to provide service providers (e.B. Assessment, diagnosis, prevention, treatment, psychotherapy, counselling) to provide comprehensive guidance. Extending the guidelines to certain areas of practice (p.B industrial/organizational psychology, counselling psychology) may require changes, although some of the same general principles may be helpful. When digitizing customer records, all data must be digitized. The new electronic document must limit future changes or be able to save the changes made, for example, . B using metadata. When scanning paper customer records, strict quality control must be performed to ensure that customer records remain complete and correct. CopPS began with an evaluation of APA members` experiences with the current guidelines. The 1993 Record-Keeping Guidelines were posted on the APA website for member and public comment in light of a possible revision. A call for comments was published in the APA Monitor and distributed to state, provincial and territorial psychological associations, as well as APA departments. COPPS also reviewed the current literature on record keeping.
The relevant provisions of the Code of Ethics (APA, 2002b), which had been extensively revised since the development of the 1993 Record-Keeping Guidelines, were reviewed in detail, as were the relevant codes of ethics and guidelines for several other psychiatric professions. COPPS has also considered the impact of applicable federal and state laws and regulations, including HIPAA. COPPS reviewed questions received from members of the Office of Legal and Regulatory Affairs of the APA Practice Directorate and the APA Ethics Office. Most often, these issues related to record content, record management and maintenance, electronic records, record keeping, and compliance with rapidly evolving state and federal record retention requirements. Finally, other ABS practice guidelines were reviewed to ensure internal consistency of ABS policies. Psychologists subject to the Health Insurance Portability and Accountability Act of 1996 should be aware of certain record-keeping requirements and considerations under the hipaa security rule and confidentiality rule (see HIPAA Administrative SIMPLIFICATION, text of the policy, 45 CFR Parts 160, 162, and 164; U. Ministry of Health and Social Services, Office of Civil Rights, 2006). These guidelines point to some key areas where HIPAA requirements or considerations affect record retention. .