Record Keeping for Psychology Practitioners

The American Psychology Association defines clear guidelines as it pertains to record keeping by psychologists. Psychologists also have to be educated and aware of HIPAA compliance regulations. In addition, almost every state has specific guidelines and rules that are required and pertain to psychologists and the many records kept.

Psychology records should be grouped into 3 main categories: general file information, documentation of service, and other information. Each group of records must be maintained and follow specific guidelines for the grouping:

General file information includes all the contact and identifying information of the patient. It includes the identification of the problem, the client’s history, and the treatment or intervention plan. Informed consent, authorization for release of information, disclosures, and financial information should all be included in the general information file.

Documentation of service includes dates, duration, and type of services provided to the patient by the psychologist. It should assess the patient’s level of fuctioning and a description of the treatement and intervention details. These documents are typically shared and accessed by other professionals.

Other information should include all contact documentation with the patient, including call notes and email records. It should also include notes on all consultations with other doctors, psychologists, and other professionals.

Psychologists need to be particuarly conscientious of therapy notes, as those usually include much more sensitive information than official documentation of treatment and issues. Therapy notes are specifically regulated by HIPAA as requiring a higher level of security and privacy.

Practitioners should have a contingency plan for the secure access and tranfer of documents in the case of an unforseen illness to the pyschologist. This can be very difficult to implement in a paper environment. Additionally, access by other practitioners with a professional need to know must be managed and appropriately guarded.

Document retention is required for a minimum of 7 years from the date of last service, or 3 years after a patient turns 18. With paper files, this can become a very time-consuming and space-consuming regulation to maintain. Therapists have found that managing the retention of documents takes up a lot of staff time, and maintaining years of documents requires massive amounts of space and supplies.

Did you know that the 2009 Health Information Technology for Economic and Clinical Act (HITECH) encourages pyschologists to transition to electronic records by 2014? Yet, thousands of phsychologists are still staggering under the immense burden of paper documents.

Organizational psychological records can make it harder to maintain privacy among employees and practitioners. An electronic document management system allows for granular, specific access into patient records according to need to know. Specific documents can be accessed while more sensitive documents can be allowed to a narrower group of professionals. This level of item-specific, role-based security is a high level of privacy that can never be achieved through filing cabinets.

Financial records, which must be kept from the onset of treatment, are made easier to maintain through a document management system. Financial practices must be clearly disclosed and treatment, payments, and billing clearly organized. Integrations with QuickBooks, Sage, and other systems make the tracking and storing of these records quick and easy.

eFileCabinet is the ideal choice for psychologists from all fields. From role-based authority to 256-bit encryption, your patients’ information is kept secure. eFileCabinet is the only solution that provides easy storing from both QuickBooks and Sage accounting software. Automated retention protects documents during the retention period, and will automatically remind the practitioner when the document should be destroyed. Documents are kept protected through automatic backup to offsite locations, which protects agains catastrophic incidents. eFileCabinet provides a secure portal for the safe, encrypted, electronic sharing of documents with other practitioners, doctors, legal counsel, patients, and outside sources with a valid need for the information.

Don’t wait! Find out today how eFileCabinet can help your practice. Fill out the form on this page.

By | 2016-12-15T11:59:32+00:00 October 30th, 2015|
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