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The many challenges in this area escape simple or immediate answers, but the following five reflections, adapted from another source (Pope & Vasquez, 2011), can be useful if we don`t just think about whether changes in legal requirements, ethical standards, and professional guidelines can be useful (and if so, what these specific changes are and how they can be implemented). but also how each of us manages our daily files as clinical psychologists. Jacovino, L. (2004). The patient-therapist relationship: reliable and authentic mental health records in a shared electronic environment. Psychiatry, Psychology and Law, 11, 63-72. In all cases where the best interests of the child are at stake, the best interests of the child are paramount. This may require disclosure of some of the contents of the medical record – or details of it – to a social worker and/or the Gardai. As a good practice, you should always explain to parents that you have an obligation to raise your concerns with non-medical professionals and, if possible, obtain their consent to disclosure, except in the rare cases where doing so would put the child at increased risk. Third, client files must be completed in a timely manner, that is, as soon as possible after the service has been provided.

This ensures an accurate recall date, especially when customers are seen back to back in busy practice. Record keeping practices may depend on the type of legal relationship the psychologist has with the organization. In some situations, the physical file of psychological services is the property of the organization and does not travel with the psychologist at the time of departure. However, in consultative relationships, ownership and responsibility for records may be maintained by the psychologist. It is therefore useful for psychologists to clarify these issues at the beginning of the relationship in order to minimize the likelihood of misunderstandings. Altering or destroying records. Many statutes, regulations and rules of evidence prohibit the amendment or deletion of information once a record has been created. In the context of litigation, the addition or deletion of information from a record that has been subpoenaed or requested by court order may engage the responsibility of the psychologist.

Psychologists can seek advice on relevant state and federal laws before modifying an existing dataset. It is recommended that you document subsequent additions to a dataset itself. The statutes of the Legal Department are not intended to provide legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and is not intended to address all situations that may arise. Please note that laws, regulations and technical standards change over time. Therefore, it is important to review and update any references or information provided in the article. In 1988, the APA`s Board of Professional Affairs (BPA) asked its Committee on Professional Practice and Standards (COPPS) to examine the potential usefulness of record-keeping guidelines for psychologists. Interviews with psychologists have shown that such guidance would indeed be useful. The HPPC also reviewed state laws and regulations relating to psychologist cases and found that they are vague and differ significantly from jurisdiction to jurisdiction.

In light of these findings, BPA asked the HPOC to initiate the development of record-keeping guidelines (APA, Committee on Professional Practice and Standards, 1993), which were subsequently adopted as ABS guidelines. Records benefit both the client1 and the psychologist by documenting treatment plans, services provided and the client`s progress. The record documents the psychologist`s planning and implementation of an appropriate service to monitor their work. Recordings can be especially important if there are significant periods between contacts or if the client uses the services of another professional. Proper records can also help protect both the client and the psychologist in the event of legal or ethical proceedings. Adequate records are usually a prerequisite for reimbursement of psychological services by third parties. Often, record creation and maintenance rules reflect the needs of all relevant disciplines, not just those related to mental health services. The involvement of the treatment team in service delivery can lead to broader access to records than is typically the case in independent practice settings. Because others (e.g., doctors, nurses, paraprofessionals, and other service providers) have access to and can register the client`s file, the psychologist has less direct control over the file. Psychologists are encouraged to participate in the development and refinement of organizational policies that maintain records. The registration process involves taking into account legal requirements, ethical standards and other external constraints, as well as the requirements of the particular professional context.

In some situations, a number of considerations may suggest a different course of action than another, and it is up to the psychologist to evaluate them appropriately. These guidelines are intended to help psychologists make such decisions. First, client records must be legible. Many psychologists continue to take handwritten notes during and after sessions. Since these notes are part of the client`s file, it is important that they can be easily read by the psychologist and, if necessary, by other psychologists or professionals.