Record Keeping

What Canadian & Provincial Codes of Ethics and Standards of Practice Have to Say

Angela Chiasson, Jo Friesen & Debby Kenna APSY 603

Opening Vignette Introduction: Importance of Record Keeping Discussion of Record Keeping Codes/Standards of Practice

Content ~ Vignette Privacy, Confidentiality & Access ~ Vignette Storage & Transfer ~ Vignette Retention ~ Vignette Ownership ~ Vignette

References Mystery Review Activity

Outline of Presentation

You are currently living in Calgary, working as a School Psychologist for a local School District where you maintain the records of all your clients. You are moving to Vancouver to open your own private clinic as a Psychologist.
Are you responsible to take records with you? Do you leave your Records with the District? If so, how long do you keep the records you have kept? If you bring your records to B.C., which Provincial legislation will the retention of your records fall under?

Vignette

Why is Record Keeping Important?

Benefit to Client Documentation of treatment plans Documentation of services provided Documentation of client progress Protection in the event of legal proceedings

Introduction
(APA, 2007)

Why is Record Keeping Important?

Benefit to Psychologist Documentation of planning Documentation of interventions, courses of action Allows for self-monitoring, accountability Important when there is a large delay in treatment or when transferring services to another professional Protection in the event of legal proceedings

It is each psychologist's responsibility to maintain and retain their own records.

Introduction
(APA, 2007)

National Provincial

General Standards Specific Standards Implementation Policies

Local

Governing Standards

When Standards Conflict:

Know before you start Advocate for change Follow the Code

Governing Standards
(Drogin et al, 2010)

When determining record content, consider what is required:

To provide good care To assist & collaborate with other professionals To ensure continuity of services For supervisory or training needs For reimbursement or under contract For effective decision making To answer legal or regulatory complaints

Content
( APA, 2007)

Things to consider regarding level of detail:

What is required to be included What is required to not be included Juvenile records, HIV test results Client wishes Context different expectations for emergency, disaster relief Requirements of third-party payers Referral needs and usage Balance obligations with level of risk

Content
( APA, 2007; Drogin et al, 2010)

GENERAL CONTENT OF RECORDS Seek and collect, with the clients consent, documented, relevant information from reliable sources.

CA AB BC NS ON

Keep records accurate, current, legible and complete.

Only record necessary private information. Create and maintain records for each client that allow for continuity and coordination of care. Record & communicate information in such a way as to minimize misinterpretation or misuse. Discuss record creation and maintenance with parents and adult students. Maintain records with sufficient detail to be useful.

It is ethically permissible to keep private notes.

Computer and software generated reports must be integrated into the body of individually written reports, unless the computer generated report is specifically designed to be used directly with clients.

Content: General

SPECIFIC CONTENT. Records should include the following: Appropriate identifying information. BC name

AB BC NS ON

Clients name, address, phone number, DOB.

Presenting problem(s) or purpose for consultation Fee arrangement Date and substance of each professional service. Any test results or other evaluative results and any basic test data from which results were derived Notations & any results of formal consults with other service providers A copy of all test and other evaluative reports prepared as part of the professional relationship Any releases or consents executed by the client NS/ON includes documentation of verbal consent

Content: Specific

SPECIFIC CONTENT. Records should include the following: A copy of all documents relied upon in the course of providing psychological services

AB BC NS ON

Date of every relevant and clinically significant contact with the client.
Information regarding services that were started, but not completed, and an explanation of why. Information on all referrals to other professionals. Ensure all entries are dated and that the identity of the person making the entry is noted. NOT required to keep information on persons receiving prevention, public education, group training, emergency or post-emergency group services or group screening services.

Content: Specific

Fee Records should include the following: Service provider(s)

AB BC NS ON

Payer
Recipient of professional services Date, nature and unit fee of the service provided Total charged Payment received Date of payment Source of payment Other information that the client may need to obtain insurance reimbursement

Content: Fee Records

You tend to be a bit of a hoarder and you have neglected to keep your file information organized you need to cull your files before you move and keep only necessary information.
What absolutely needs to be in your files?

Content: Vignette

Privacy & Confidentiality

Must meet governing standards Necessary to promote trust Conflicts guided by The Code

Privacy, Confidentiality & Access to Records

( APA, 2007)

Access:

Best practice: Assume at some point any client may ask to access his or her (or their childs) records Best practice: Understand and communicate third-party access obligations up front (school personnel, insurance)

Privacy, Confidentiality & Access to Records

( Truscott & Crook, 2004)

Privacy, Confidentiality & Access to Records Maintain privacy and security all of records, including during collection, storage, handling and transferring of information. Ensure clients, or parents of minor clients, have appropriate access to their records. Ensure school records are not released to persons or agencies outside the school without parent consent, unless required or permitted by law. Only allow school personnel who have a legitimate educational interest access to school psyc records, unless specific consent is given. Only collect and record information necessary to respond to the needs of the client. Ensure information from records is not used to violate a clients rights or privacy. Develop procedures to allow clients to correct errors in their records.

CA AB BC NS ON

Privacy, Confidentiality & Access to Records

Privacy, Confidentiality & Access to Records Inform clients of limits to confidentiality.

CA AB BC NS ON

Avoid releasing information that requires expertise to interpret

If appropriate, use coding to protect personal identification. Protect the security of standardized tests. Store all files, paper and electronic, securely. May fully disclose interpreted test findings and test data, but not actual test materials. When records are a part of a common record, take care to ensure information will not be misused or misinterpreted.

Privacy, Confidentiality & Access to Records

You just nicely get settled in Vancouver when you get a letter from McInnis Barristers and Solicitors. A family of a Special Needs child in your Calgary district is suing your old District. They claim that the confidentiality of their childs private information was jeopardized in your district. The legal firm is requesting that you forward your file to them so they can investigate. You begin to reflect on your practice did you ensure confidentiality at all times? What best practice should you have been using to ensure confidentiality and student privacy?

Privacy, Confidentiality & Access: Vignette

Storage and Transfer of Records Develop methods that are logical and consistent Best practice: Create separate sections in files that may be accessed by others to ensure they only access applicable sections Have back-up system in place before it is needed!

Storage & Transfer

(Drogin et al, 2010)

Storage and Transfer of Records Parents and clients have a right to understand how records are stored and maintained, and any associated risks to privacy. Protect records from unauthorized release. Safeguard any loss of records. Advocate for district policies that safeguard security, allow appropriate access, provide for periodic review, dispose of records responsibly. If using an organization-wide record-keeping system, be responsible to control and safeguard their portion of record. Store and dispose of records in a manner that ensures confidentiality and security. Design electronic systems to guard against loss, tampering, interference, or unauthorized use or access.

CA AB BC NS ON

Storage & Transfer

You have packed everything up your life is in boxes! You have got quotes from two moving companies: Big Bad Bills moving (he lives down the street, does moving on the side, and will move you to B.C. for less than you could rent a U-Haul for). North America Moving Company (a large company who is bonded and guaranteed secure but more than triple the cost of Big Bad Bill!)
Does it matter who you move your belongings with? It is you who is footing the bill!

Storage & Transfer: Vignette

Consider:

Differences between provinces What circumstances may require retention of records beyond the minimum time frame How to track and dispose of records no longer needed (confidentiality!)

Retention

Retention Must maintain records for at least 10 years after date of last professional service. Must maintain records for at least 7 years after date of last professional service. Must maintain minor records for at least 7 years after minor reaches age of majority. Must maintain minor records for at least 10 years after the minors 18th birthday. Supervisory records must be kept for a minimum of 7 years after the date of last supervised activity.

CA AB BC NS ON

Retention

You pull out the childs file and you notice that the last time you had contact with the special needs child in question was November 2nd, 2000. Legally, do you still need to retain the file? Does the fact that you are now in B.C. and the child is in Alberta have any bearing in this dilemma, given that B.C. and Alberta clearly have different retention laws?

Retention: Vignette

Ownership:

Know before you start! Communicate with your client Have a plan

Ownership

Ownership Have adequate contingency plans in place for what to do with records in case of own serious illness, change of employment or death. Before retiring ensure primary responsibility is transferred to another qualified professional &that this transfer is communicated to the College Before retiring ensure clients are notified in a timely manner and given the opportunity to obtain their own copies of their client record or have records transferred to professional of their choice

CA AB BC NS ON

Ownership

With the latest law suit surfacing, you decide it is time to retire.
What best practice safeguards do you now put in place when anticipating your impending retirement?

Ownership: Vignette

American Psychological Association. (2007.) Record keeping guidelines. American Psychologist, 62 (9), 993-1004. Retrieved from http://www.apa.org/practice/guidelines/record-keeping.pdf BC Association of School Psychologists. (2010). Ethical conduct and professional practice. Vancouver: Author. Retrieved from http://www.bcasp.ca/cms_pdfs/Ethics%20March%202010.pdf Canadian Psychological Association. (2000) Canadian code of ethics for psychologists (3rd ed). Ottawa: Author. Retrieved from http://www.cpa.ca/cpasite/userfiles/Documents/Canadian%20Code%20of%20Ethics%20for%20Ps ycho.pdf Canadian Psychological Association. (2001). Practice guidelines for providers of psychological services. Ottawa: Canadian Psychological Association. Retrieved from http://www.cpa.ca/cpasite/userfiles/Documents/publications/Practice%20Guidelines2001%282% 29.pdf College of Alberta Psychologist. (2000). Code of conduct. Edmonton, AB: Author. Retrieved from http://library.athabascau.ca/caap603/codeofconduct.pdf

References

College of Alberta Psychologists. (2005). Control and use of tests by psychologists. Edmonton, AB: Author. Retrieved from http://www.cap.ab.ca/pdfs/HPAPGFP-ControlandUseofTests.pdf College of Alberta Psychologists. (2005). Standards of practice. Edmonton, AB: Author. Retrieved from http://www.cap.ab.ca/pdfs/HPAStandardsofPractice.pdf College of Psychologists of BC. (2009) Code of conduct. Vancouver, BC: Author. Retrieved from http://www.collegeofpsychologists.bc.ca/documents/Code%20of%20Conduct%202009%20full%2 0page%20version.pdf Drogin, E.Y., Connell, M., Foote, W.E., Sturm, C.A. (2010). The American Psychological Associations revised Record Keeping Guidelines: Implications for the practitioner. Professional Psychology: Research and Practice, 41 (3), 236-243. National Association of School Psychologists. (2010) Principles for professional ethics. Bethesda, MD: Author. Retrieved from http://www.nasponline.org/standards/2010standards/1_%20Ethical%20Principles.pdf

References

Nova Scotia Board of Examiners in Psychology. (2007) Standards of practice. Halifax, NS: Author. Retrieved from http://www.nsbep.org/downloads/Binder_Standards_Legislation_Guidelines.pdf The College of Psychologists of Ontario. (2005). Standards of professional conduct. Toronto, ON: Author. Retrieved from http://www.cpo.on.ca/assets/60F48DEF-3513-490F-B502FD46ADA6B78A.pdf

Truscott, D. & Crook, K. (2004). Ethics for the practice of psychology in Canada. Edmonton, AB: University of Alberta Press

References

Mystery Review Activity