Reports of the Association

Record Keeping Guidelines

Drafted by the Committee on Professional Practice & Standards,
A committee of the Board of Professional Affairs
Adopted by the Council of Representatives,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

February 199 S

Introduction1 legal purposes. State and federal laws in many cases re-
quire maintenance of appropriate records of certain kinds
The guidelines that follow are based on the General of psychological services. Adequate records may be a re-
Guidelines, adopted by the American Psychological As-
sociation (APA) in July 1987 (APA, 1987). The guidelines
1
receive their inspirational guidance from specific APA In 1988 the Board of Professional Affairs (BPA) directed the Committee
Ethical Principles of Psychologists and Code of Conduct on Professional Practice and Standards (COPPS) to determine whether
record keeping guidelines would be appropriate. COPPS was informed
(APA, 1992). that these guidelines would supplement the provisions contained in the
These guidelines are aspirational and professional General Guidelines for Providers of Psychological Services, which had
judgment must be used in specific applications. They are been amended two years earlier. The Council of Representatives approved
intended for use by providers of health care services.23 the General Guidelines records provisions after extended debate on the
minimum recordation concerning the nature and contents of psycho-
The language of these guidelines must be interpreted in logical services. The General Guidelines reflect a compromise position
light of their aspirational intent, advancements in psy- that psychologists hold widely varying views on the wisdom of recording
chology and the technology of record keeping, and the the content of the psychotherapeutic relationship. In light of the Council
professional judgment of the individual psychologist. It debate on the content of psychological records and the absence of an
integrated document, BPA instructed COPPS to assess the need for such
is important to highlight that professional judgment is guidelines, and, if necessary, the likely content.
not preempted by these guidelines; rather, the intent is COPPS undertook a series of interviews with psychologists expe-
to enhance it. rienced in this area. The consensus of the respondents indicated that
practicing psychologists could benefit from guidance in this area. In
Underlying Principles and Purpose addition, an APA legal intern undertook a 50-state review of laws gov-
erning psychologists with respect to record keeping provisions. The survey
Psychologists maintain records for a variety of reasons, demonstrated that while some states have relatively clear provisions gov-
the most important of which is the benefit of the client. erning certain types of records, many questions are often left unclear.
Records allow a psychologist to document and review the In addition, there is a great deal of variability among the states, so that
consistent treatment of records as people move from state to state, or
delivery of psychological services. The nature and extent as records are sought from other states, may not be easy to achieve.
of the record will vary depending upon the type and pur- Based on COPPS' survey and legal research, BPA in 1989 directed
pose of psychological services. Records can provide a his- COPPS to prepare an initial set of record keeping guidelines. This doc-
tory and current status in the event that a user seeks psy- ument resulted.
2
chological services from another psychologist or mental These guidelines apply to Industrial/Organizational psychologists
health professional. providing health care services but generally not to those providing non-
health care I/O services. For instance, in I/O psychology, written records
Conscientious record keeping may also benefit psy- may constitute the primary work product, such as a test instrument or
chologists themselves, by guiding them to plan and im- a job analysis, while psychologists providing health care services may
plement an appropriate course of psychological services, principally use records to document non-written services and to maintain
to review work as a whole, and to self-monitor more pre- continuity.
3
Rather than keeping their own record system, psychologists prac-
cisely. ticing in institutional settings comply with the institution's policies on
Maintenance of appropriate records may also be record keeping, so long as they are consistent with legal and ethical
relevant for a variety of other institutional, financial, and standards.

984 September 1993 • American Psychologist

Copyright 1993 by the American Psychological Association, Inc. OOO3-O66X/93/J2.OO
Vol. 48, No. 9, 984-986
 quirement for receipt of third party payment for psycho- when preparing records. Psychologists adequately identify
logical services. impressions and tentative conclusions as such.
In addition, well documented records may help pro-
tect psychologists from professional liability, if they be-
2. Construction and Control of Records
come the subject of legal or ethical proceedings. In these a. Psychologists maintain a system that protects the
circumstances, the principal issue will be the professional confidentiality of records. They must take reasonable steps
action of the psychologist, as reflected in part by the to establish and maintain the confidentiality of infor-
records. mation arising from their own delivery of psychological
At times, there may be conflicts between the federal, services, or the services provided by others working under
state or local laws governing record keeping, the require- their supervision.
ments of institutional rules, and these guidelines. In these b. Psychologists have ultimate responsibility for the
circumstances, psychologists bear in mind their obliga- content of their records and the records of those under
tions to conform to applicable law. When laws or insti- their supervision. Where appropriate, this requires that
tutional rules appear to conflict with the principles of the psychologist oversee the design and implementation
these guidelines, psychologists use their education, skills of record keeping procedures, and monitor their observ-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

and training to identify the relevant issues, and to attempt ance.

This document is copyrighted by the American Psychological Association or one of its allied publishers.

to resolve it in a way that, to the maximum extent feasible, c. Psychologists maintain control over their clients'
conforms both to law and to professional practice, as re- records, taking into account the policies of the institutions
quired by ethical principles. in which they practice. In situations where psychologists
Psychologists are justifiably concerned that, at times, have control over their clients' records and where cir-
record keeping information will be required to be dis- cumstances change such that it is no longer feasible to
closed against the wishes of the psychologist or client, and maintain control over such records, psychologists seek to
may be released to persons unqualified to interpret such make appropriate arrangements for transfer.
records. These guidelines assume that no record is free d. Records are organized in a manner that facilitates
from disclosure all of the time, regardless of the wishes their use by the psychologist and other authorized persons.
of the client or the psychologist. Psychologists strive to assure that record entries are legi-
ble. Records are to be completed in a timely manner.
1. Content of Records e. Records may be maintained in a variety of media,
so long as their utility, confidentiality and durability are
a. Records include any information (including in- assured.
formation stored in a computer) that may be used to
document the nature, delivery, progress, or results of psy- 3. Retention of Records
chological services. Records can be reviewed and dupli- a. The psychologist is aware of relevant federal, state
cated. and local laws and regulations governing record retention.
b. Records of psychological services minimally in- Such laws and regulations supersede the requirements of
clude (a) identifying data, (b) dates of services, (c) types these guidelines. In the absence of such laws and regu-
of services, (d) fees, (e) any assessment, plan for inter- lations, complete records are maintained for a minimum
vention, consultation, summary reports, and/or testing of 3 years after the last contact with the client. Records,
reports and supporting data as may be appropriate, and or a summary, are then maintained for an additional 12
(f) any release of information obtained. years before disposal.4 If the client is a minor, the record
c. As may be required by their jurisdiction and cir- period is extended until 3 years after the age of majority.
cumstances, psychologists maintain to a reasonable degree b. All records, active and inactive, are maintained
accurate, current, and pertinent records of psychological safely, with properly limited access, and from which timely
services. The detail is sufficient to permit planning for retrieval is possible.
continuity in the event that another psychologist takes
over delivery of services, including, in the event of death, 4. Outdated Records
disability, and retirement. In addition, psychologists a. Psychologists are attentive to situations in which
maintain records in sufficient detail for regulatory and record information has become outdated, and may there-
administrative review of psychological service delivery. fore be invalid, particularly in circumstances where dis-
d. Records kept beyond the minimum requirements closure might cause adverse effects. Psychologists ensure
are a matter of professional judgment for the psychologist. that when disclosing such information that its outdated
The psychologist takes into account the nature of the psy- nature and limited utility are noted using professional
chological services, the source of the information re- judgment and complying with applicable law.
corded, the intended use of the records, and his or her
professional obligation. 4
These time limits follow the APA's specialty guidelines. If the spe-
e. Psychologists make reasonable efforts to protect cialty guidelines should be revised, a simple 7 year requirement for the
against the misuse of records. They take into account the retention of the complete record is preferred, which would be a more
anticipated use by the intended or anticipated recipients stringent requirement than any existing state statute.

September 1993 • American Psychologist 985

 b. When records are to be disposed of, this is done b. Psychologists may charge a reasonable fee for re-
in an appropriate manner that ensures nondisclosure (or view and reproduction of records. Psychologists do not
preserves confidentiality) (see Section 3a). withhold records that are needed for valid healthcare
purposes solely because the client has not paid for prior
5. Disclosure of Record Keeping services.
Procedures REFERENCES
American Psychological Association. (1987). General guidelines for
a. When appropriate, psychologists may inform providers of psychological services. American Psychologist, 42, 712-
their clients of the nature and extent of their record keep- 723.
American Psychological Association. (1992). Ethical principles of psy-
ing procedures. This information includes a statement chologists and code of conduct. American Psychologist, 47, 1597-
on the limitations of the confidentiality of the records. 1611.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

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986 September 1993 • American Psychologist