Monitor on Psychology - February 2012 - (Page 72)

In addition, psychologists must plan for retirement and the eventual disposal of their records. APA revised its Record Keeping Guidelines in 2007 in response to evolving technologies, the advent of electronic health records, the impact of the Health Insurance Portability and Accountability Act and the complexities of record keeping in various organizational settings. As APA practice guidelines, the guidelines are aspirational and complement the mandatory APA Ethical Standards (APA, 2010) that relate to documentation. The APA guidelines are designed to “educate psychologists and provide a framework for making decisions regarding professional record keeping.” There are 13 guidelines in all, each followed by a rationale detail kept in records. These can include the client’s wishes for more limited records; the service context or setting; legal and regulatory mandates; and contractual requirements of thirdparty payers. APA’s Record Keeping Guidelines delineate three types of content: • General file information: This includes identifying data and contact information; presenting problems and diagnosis; client history; treatment or intervention plan; fee agreement and billing information; and documented informed consent (Ethics Code, 3.10). Authorizations for release of information (Ethics Code, 4.05) and documentation of any mandated disclosures of confidential data may also be included. Psychotherapy notes, which may include more detailed or sensitive client information, must be kept separately from the general record in order to be afforded heightened protection under the HIPAA Privacy Rule. and examples that illustrate how the guideline may be applied in practice. The guidelines appear at www.apa.org/practice/ guidelines/index.aspx. This article offers an overview of the guidelines and the key points psychologists should consider as they develop their own record-keeping systems. Psychologists’ responsibilities Practicing psychologists can tailor their record-keeping practices to their setting, type of practice and the characteristics of their treatment or assessment population. Psychological records document the nature, delivery, progress and outcomes of services. Records facilitate the coordination of care, as well as the process of transition to other levels of care, and referral or termination. Accurate records can support the clinician in resolving disputes on such issues as the quality of the services provided, fee agreements or treatment progress. Others who handle records — such as the psychologist’s employees — should be trained to handle confidential client information with the same level of care. The organizational structure and content of records may be influenced by a variety of factors. Recognizing that psychologists work in diverse settings, APA’s Record Keeping Guidelines list basic components of the psychological record — general file information, documentation of service and specific information related to the individual characteristics of the treatment. Various factors may influence the amount of 72 • Documentation of service: This includes the date, duration and type of service that the psychologist provides and should be updated for each substantive contact with a client. Such documentation may include a description of the treatment modality or specific intervention and an assessment of the client’s current level of functioning. Recognizing that clients and other professionals may review these records, the practitioner may want to be sensitive to the language he or she uses to describe the patient. • Other information: A variety of other types of information may be included in the record, such as assessment data, crisis management documentation, consultation with other professionals, and telephone and email contacts. Psychotherapy notes, which may include more detailed or sensitive client information, must be kept separately from the general record in order to be afforded heightened protection under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. For example, health insurers cannot obtain them without a completely voluntary patient authorization. The extent to which psychotherapy notes are protected from patient requests for access varies because state laws that give patients greater access to their records can preempt the Privacy Rule provision providing no access to psychotherapy notes. APA’s Legal and Regulatory department provides guidance and current updates on HIPAA-related issues at www.apapracticecentral.org/business/hipaa/index.aspx. M o n i t o r o n p s y c h o l o g y • F e b ru a ry 2 0 1 2 http://www.apa.org/practice/guidelines/index.aspx http://www.apa.org/practice/guidelines/index.aspx http://www.apapracticecentral.org/business/hipaa/index.aspx

Table of Contents for the Digital Edition of Monitor on Psychology - February 2012

Monitor on Psychology - February 2012
Letters
President’s column
Contents
From the CEO
APA files two briefs in support of same-sex couples
New registry seeks to understand addiction recovery through ‘crowdsourcing’
APA launches a database of tests and measures
Watch for new member benefit: “APA Access”
Apply now for APA’s Advanced Training Institutes
PsycTHERAPY, APA’s new database, brings therapy demos to life
In Brief
APA scientists help guide tobacco regulation
A-mazing research
‘A machine for jumping to conclusions’
Judicial Notebook
Random Sample
Righting the imbalance
The beginnings of mental illness
Science Directions
Improving disorder classification, worldwide
Protesting proposed changes to the DSM
Interventions for at-risk students
Harnessing the wisdom of the ages
Anti-bullying efforts ramp up
Hostile hallways
R U friends 4 real?
Support for teachers
Speaking of Education
Record keeping for practitioners
Going green
At the intersection of law and psychology
Division Spotlight
Grants help solve society’s problems
Personalities

Monitor on Psychology - February 2012