§ 41.57. Professional records.
(a) This section sets out the Board’s minimum requirements for the maintenance of professional records by psychologists. These requirements express the Board’s belief that a psychologist’s commitment to the welfare of a client/patient includes the duty to record accurately that person’s progress through the evaluation and intervention process. Compliance with this section does not excuse psychologists from complying with stricter standards otherwise imposed by State or Federal law or regulation or by institutional requirements.
(b) A psychologist shall maintain a legible record for each client/patient which includes, at a minimum:
(1) The name and address of the client/patient and, if the client/patient is a minor, the names of the parents or the name of the legal guardian. If a minor’s parents are separated, notation of legal custodial arrangements is required.
(2) The presenting problem or purpose or diagnosis.
(3) The fee arrangement.
(4) The date and substance of each service contact.
(5) Test results or other evaluative results obtained and basic test data from which they were derived.
(6) Notation and results of formal consults with other providers.
(7) A copy of all test or other evaluative reports prepared as part of the professional relationship.
(8) Authorizations, if any, by the client/patient for release of records or information.
(c) A psychologist shall store and dispose of written, electronic and other records in a manner which insures their confidentiality.
(d) To meet the requirements of this section, so as to provide a formal record for review, but not necessarily for other legal purposes, a psychologist shall assure that all data entries in professional records are maintained for at least 5 years after the last date that service was rendered. A psychologist shall also abide by other legal requirements for record retention, even if longer periods of retention are required for other purposes.
(e) A psychologist shall provide for the confidential disposition of records in the event of the psychologist’s withdrawal from practice, incapacity or death.
(f) Failure to comply with this section shall subject the violator to disciplinary action under section 8(a)(15) of the act (63 P. S. § 1208(a)(15)).
Authority The provisions of this § 41.57 issued under section 3.2(2) of the Professional Psychologists Practice Act (63 P. S. § 1203.2(2)).
Source The provisions of this § 41.57 adopted June 12, 1992, effective June 13, 1992, 22 Pa.B. 2980.
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