ethics and record keeping

Eric Harris (2012), longtime legal counsel to the American Psychological Association Insurance Trust on areas related to risk management, has described elements required for appropriate clinical record keeping. Harris lists the following information for inclusion in the clinical record:

  • Medication prescription and monitoring
  • Start and stop times of each counseling session
  • Modality and frequency (once a week, biweekly, etc.) of treatment
  • Results of clinical tests (including raw test data)
  • Summaries of diagnosis, symptoms, treatment plan, progress to date, and prognosis
  • Paper records must be kept under secure lock and key.

In addition to psychotherapy notes kept by clinicians, digital records should include e-mail communications, text messages, and audio and/or video files generated from work with clients. Every reasonable precaution should be taken to preserve the confidentiality of the digital records. This includes use of appropriate encryption services, up-to-date virus definitions and anti-virus software, and record storage and backup.

Maximum security passwords (and/or thumb print or eye scanners) should be used on computers storing client information. Many states now require that client records kept on computers without duplicate hard copy records must be made unalterable after they are entered into a computer. Good sources of information on this area of practice include the following:

  • 2010 APA Ethical Principles of Psychologists and Code of Conduct
  • APA Record Keeping Guidelines 2008
  • APA Division 29 Telepsychology Guidelines

Post by Day 4 a description of three ethical considerations relevant to record keeping that psychologists may face. Describe the specific challenges that may arise because of these ethical considerations. Then explain how you will best protect your clients’ records that are in both electronic and hard copy formats. Explain what resources (other than those mentioned above) you might use for up-to-date, reliable information in creating your practice with regard to client records and their protection. Be sure to include references to any applicable APA ethical codes.

Read a selection of your colleagues’ postings.

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