Record Keeping Guidelines

Introduction

These guidelines are designed to educate psychologists and provide a framework for making decisions regarding professional record keeping. State and federal laws, as well as the American Psychological Association's (APA, 2002b) "Ethical Principles of Psychologists and Code of Conduct" (hereafter referred to as the Ethics Code), generally require maintenance of appropriate records of psychological services. The nature and extent of the record will vary depending upon the purpose, setting, and context of the psychological services. Psychologists should be familiar with legal and ethical requirements for record keeping in their specific professional contexts and jurisdictions. These guidelines are not intended to describe these requirements fully or to provide legal advice.

Records benefit both the client1 and the psychologist through documentation of treatment plans, services provided, and client progress. Record keeping documents the psychologist's planning and implementation of an appropriate course of services, allowing the psychologist to monitor his or her work. Records may be especially important when there are significant periods of time between contacts or when the client seeks services from another professional. Appropriate records can also help protect both the client and the psychologist in the event of legal or ethical proceedings. Adequate records are generally a requirement for third-party reimbursement for psychological services.

The process of keeping records involves consideration of legal requirements, ethical standards, and other external constraints, as well as the demands of the particular professional context. In some situations, one set of considerations may suggest a different course of action than another, and it is up to the psychologist to balance them appropriately. These guidelines are intended to assist psychologists in making such decisions.

1The term client is used throughout this document to refer to the child, adolescent, adult, older adult, family, group, organization, community, or other population receiving psychological services. Although it is recognized that the client and the recipient of services may not necessarily be the same entity (APA Ethics Code, Standard 3.07), for economy the term client is used in place of service recipient.