How Long Mental Health Records Are Keepen by Psychologists?
The length of time that psychologists keep clinical records varies by setting and practice type. The American Psychological Association (APA) provides guidelines to guide record-keeping practices.
Psychologists who provide services in institutional settings such as hospitals or university counseling centers need to follow any record retention requirements of the institution. They also should be aware of the conflicts that may arise between these requirements and their own ethical principles.
Federal Requirements
APA ethical and legal standards as well as state, federal, and organizational requirements require psychologists to maintain appropriate records of their services. The record may vary in scope, but it typically identifies the client, the date of service, and the psychologist’s name.
In some settings, including community agencies and disaster relief programs, the psychologist’s role is limited to the creation of a brief record, with less detail than would be required in a more comprehensive setting. In such cases, the psychologist has to determine what is necessary to ensure that the client’s needs are met.
Psychologists also have to make decisions about how long to keep records. These decisions often involve balancing competing considerations, such as legal and ethical standards, state law, and the demands of the psychologist’s particular professional context.
State Requirements
Depending on the state in which you practice, your records may be subject to different requirements. APA’s Record Keeping Guidelines and your state psychology licensing board or psychological association may be able to provide you with guidance about the minimum requirements in your area.
In addition to HIPAA regulations and federal statutes, many states have their own laws that govern mental health medical records privacy and confidentiality. In some cases, these laws are more restrictive than the HIPAA requirements.
For example, New Mexico law allows the disclosure of information from a client’s mental health record to another facility or provider only when the request is made by a responsible professional and the request is for treatment purposes. Similarly, Iowa law permits disclosure of patient information to other providers when the client requests it in an emergency or when the transfer is requested by the legal representative.
Retention Schedules
When developing a records retention schedule, organizations and providers should look at federal record retention requirements as well as state-specific retention requirements. They also should review accreditation agency standards.
Mental health facilities should have a retention policy that outlines how long records are kept, which should be in line with the applicable state and federal requirements. This policy should be reviewed with legal counsel.
The first step in creating a retention schedule is to determine what types of records need to be maintained. This includes determining the types of records that are active and inactive.
Active records are those that are used for routine functions, such as release of information requests, revenue integrity audits or quality reviews. Inactive records are those that are not consulted or rarely accessed.
Legal Requirements
Psychologists need to be aware of the legal requirements for how long mental health records are kept. These laws may differ from state to state, but they usually require psychologists to maintain records until seven years after the last date of service for adult clients or three years after a minor reaches the age of majority.
Some states, however, have laws that allow mental health professionals to share their client’s records with other facilities and agencies. This may happen in the case of a medical emergency or when a patient’s legal representative requests it.
It’s important to keep in mind that psychologists should be careful not to disclose any information that might be relevant to a court case or other legal action, or that might result in a loss of confidential information.
APA’s Record Keeping Guidelines provide guidance on this important topic. They help psychologists balance competing considerations, such as client confidentiality and the professional demands of their particular practice context.
