Legal/regulatory. Certain laws and regulations require the inclusion or exclusion of certain information. For example, an institutional record-keeping rule may prohibit reference to sealed records of minors or HIV test results, or a law may regulate the disclosure of information about the treatment of chemical dependence. The psychologist takes into account the laws and regulations that govern the practice and observes the mandates when making decisions about the details of the file. Reason: Recordings can have a significant impact on the lives of customers (and previous customers). Sometimes the information in a client`s file is specific to a particular temporal or situational context (e.g., the time and situation in which the services were provided and the dataset was created). As this context changes over time, the relevance and meaning of the information may also change. Maintaining the context of the recording protects the customer from misuse or misinterpretation of this data in a way that could affect or harm the customer. Collection. Psychologists may consider including information about collection efforts in the file, including documentation of the notice of intent to use a collection service. Application: The psychologist is encouraged to update active files to reflect the professional services provided to the client and changes in the client`s status. The psychologist can use a variety of methods to organize records to facilitate storage and retrieval. Methods that reflect consistency and logic are probably the most useful.
For example, a logical file labeling system makes it easier to find and retrieve records. The psychologist may consider dividing client files into two or more sections. Psychotherapy notes, as defined by HIPAA, are necessarily separated from other parts of the recording. In addition, customer information that may be considered useful to others and should be shared with them may form a section. A psychologist may also consider, for convenience and organizational reasons, an additional section that includes material created by the client or third parties, such as family members of the client, or by previous treatment providers. These may include, but are not limited to, behavioral assessments or diaries, diaries, diaries, letters from the client`s children, photos or videos, or greeting cards. Since psychological test data may need to be examined more carefully before being released, it can be aggregated and named in the file to ensure that its disclosure is adequately considered. Now that Regulation 20 has established requirements for the retention of certain records, attention is being drawn to how records must be retained. “The company must be able to document that the food is not adulterated or mislabeled and that its history can be traced.
The Company may decide what information it wishes to retain as documentation in order to achieve this purpose. All retained documents (with a few exceptions) can be retrieved from the FDA or USDA; And failure to keep records to prove that the food has not been adulterated or mislabeled will result in the suspect food being treated as adulterated or mislabeled and therefore cannot be sold. Food businesses – you know what to do and you know the consequences if you don`t; Now it`s up to you to determine how you want to keep records for your business. “The psychologist can consult with colleagues in the organization to support record keeping, which meets the needs of different disciplines while adhering to acceptable record retention requirements and guidelines. In addition, the psychologist may review local, state, and federal laws and regulations relating to that organization and its record-keeping practices. If there is a conflict between an organization`s policies and procedures and the Code of Ethics, psychologists clarify the nature of the conflict, publish their ethical obligations, and resolve the conflict in accordance with those obligations (Code of Ethics, Standard 1.03). Contracts with third parties. The psychologist considers whether the decision to keep less detailed records differs from the contracts between the psychologist and third-party payers. Many third-party payer contracts require certain information to be included in the dataset. Psychologists who sign but fail to honour contracts with these payers may face a number of negative consequences (e.g., mandatory repayment of funds previously received, legal action).
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. Psychologists may encounter situations where it is not immediately clear who should have access to records. For example, children undergoing treatment after the dissolution of the marriage may be brought to the service by a parent who wants the records to be kept confidential by the other parent, or a teenager who is close but not quite of age may request that the records be kept confidential by the parent or guardian.