The forms and documentation items that psychologists use to evaluate, treat, and track the progress of their patients vary from state to state and from practice to practice. According to the American Psychological Association, “the organization structure and content of records may be influenced by a variety of factors,” meaning that there isn’t a standard record-keeping policy that is observed across the board for psychologists in regards to patient information.
However, in general terms, the forms that psychological professionals use to record and track patient information fall into a few basic categories. The APA defines these categories as “general file information, documentation of service, and specific information related to the individual characteristics of treatment.”
More specific form types that might fall into these categories include medical history information, diagnostic notes and assessments, treatment plans, progress reports, treatment plan updates, and more. All of these forms would be subject to the APA’s rather stringent standards for confidentiality, doctor-patient disclosure, maintenance and security of records, and document retention—requirements that make electronic document management a must for psychologists.
Information Collected on Patient Forms
As in most scenarios where document management policies are a necessary precaution, the psychological care industry must protect patient-related forms and documents due to the personal and sensitive nature of the information included on those forms.
First of all, psychology document management is important due to the simple existence of the doctor-patient confidentiality rule. Even without such a requirement, though, patients would still likely demand proper security, protection, and overall management of their information—because of the information that medical documents can include. For reference, here are some of the types of information that a psychologist might collect on patient forms as divided based on the general categories provided by the APA.
- “General File Information”: In most cases, a general file information form for a psychologist would be similar—if not identical—to the patient intake forms used at hospitals, doctor’s offices, and in other medically-related circumstances. On this form, the patient would provide his or her contact information (name, phone number, and street address), as well as other facts, like age, date of birth, emergency contact information, primary physician information, and more. A general file information form would also provide space for the patient to provide an explanation of his or her current condition or issue, thereby providing a psychologist with a basic foundation of information for assessment, diagnostics, and treatment.
- “Documentation of Service”: This category is much larger than general file information and could pertain to virtually any forms or documentation produced during patient appointments. For instance, one form in this category might include the diagnostic assessment that the psychologist would write following their initial appointments(s) with a patient. Such a piece of documentation would be less of a form and more of a report, including descriptions of the patient’s symptoms, why that person is seeking psychological treatment, whether or not that person has received psychiatric treatment in the past, relevant information about drug, alcohol, or substance abuse, information about family or personal relationships, and more. Essentially, this report would include the psychologist’s comprehensive assessment of the patient, which would, in turn, serve as an aid for designing an appropriate treatment plan.
- “Specific Information Related to the Individual Aspects of the Treatment”: This category includes forms, notes, and reports outlining the psychologist’s expert opinions on the patient and their plans for treatment. In addition to a comprehensive treatment plan, which would follow the assessment/diagnostic report discussed above, documentation in this category might include forms charting a patient’s progress and recording how that patient is responding to the treatment plan. These files would also document the full treatment narrative, gauging any progress or charting any treatment plan updates or revisions in the event of a non-effective treatment.
The Importance of Document Management for Psychologists
In any healthcare situation, patient intake forms, diagnostic reports, and treatment forms might include information that a patient would want to keep fully confidential. Doctor-patient confidentiality—and, by extension, medical record management—is important for this very reason. Given how mental illness and psychological treatment are often stigmatized in a way that other forms of medical care are not, though, confidentiality and smart document management policies have perhaps even higher stakes for psychologists and their patients.
As such, the APA has numerous requirements pertaining to data collection, electronic records storage, and other factors of psychology document management. For instance, the APA requires that psychologists disclose their recordkeeping procedures to patients as “part of the broader process of informed consent.” Psychologists must tell their patients what information they will collect, how that information will be used, whether that information will be shared with other medical professionals, and more.
The APA calls on psychologists to have “a security plan that provides adequate protection for either paper or electronic records from loss or damage.” These policies must ensure that only “trained professionals or others with a legitimate need” can access patient documents.” The APA also urges caution in sharing patient documents via unsecured communication channels like email and fax and reminds doctors to remain compliant with HIPAA (the Health Insurance Portability and Accountability Act of 1996) in storing and protecting patient documents electronically.
APA guidelines also mention document retention, recommending that psychologists retain full records of their patients “until seven years after the last date of service delivery for adults” or “until three years after a minor reaches the age of majority.” The association does mention, though, that state laws may supersede these recommendations.
Finding a Psychology Document Management System
If you are looking for an electronic document management system for your psychological care practice, look no further than eFileCabinet. With features such as 256-bit file encryption, user-based access permissions, automated document deletion or archival for retention purposes, redundant file storage, and an advanced client portal for secure electronic transmission of files, eFileCabinet meets all of the guidelines laid forth by the APA for psychologists. The software is also HIPAA compliant, making it an ideal choice for medical record management in the digital age.
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