Monitor on Psychology - February 2012 - (Page 73)

Confidentiality Protecting clients’ privacy and ensuring their trust is a key principle of documentation. Whether or not a practitioner can release client information requires the psychologist to be aware of several legal and regulatory requirements, including mandated reporting requirements. The Record Keeping Guidelines encourage psychologists to be familiar with ethical standards regarding confidentiality, specifically APA Ethics Code 4.01 and 6.02, and relevant legal, regulatory and statutory requirements. Psychologists also need to follow any applicable institutional policies. Special attention is warranted in decisions related to the access or disclosure of records of minor children, especially in situations of divorce where information may be used in adversarial proceedings such as custody conflicts. Disclosing record-keeping procedures The guidelines consider disclosure of “the nature and extent of record keeping procedures” part of the broader process of informed consent to psychological services (Ethics Code 3.10); Ethics Code 3.10d specifically requires documentation of informed consent. Psychologists are ethically mandated to discuss the “relevant limitations of confidentiality” and the “foreseeable uses of the information” (APA Ethics Code 4.02) at the outset of services. This discussion helps clients understand that their information may be shared with others and that there are potential limits to confidentiality, such as in a litigation context or mandated treatment. Maintenance and security APA’s record-keeping guidelines also recognize the importance of multidisciplinary collaboration in providing patient care. Accurate records facilitate adjunctive treatment, such as medication management, coordinated care for chronic illness or family therapy intervention. Should an unforeseen illness befall the psychologist, an up-to-date record facilitates the successful transfer of care. Records may also be requested by the client, or his or her attorney, for other uses, such as divorce or other legal proceedings, applications for disability or life insurance, or requirements for certain types of employment. Practitioners need to have a security plan that provides adequate protection for either paper or electronic records from loss or damage, and ensures only appropriate access by trained professionals or others with a legitimate need to see them. With expanding wireless and computer technologies, client data may be kept in various electronic formats, such as emails, text messages and online scheduling calendars. Practitioners should be particularly cautious when exchanging protected health information via fax, email, text messaging and electronic claims submission. Many psychologists store patients’ electronic records on their office computers, laptops and tablets. However, psychologists must be vigilant in preventing unauthorized access to the data and protecting the actual equipment from theft. Data F e b ru a ry 2 0 1 2 • M o n i t o r o n p s y c h o l o g y breaches reported under the HIPAA Breach Notification are frequently the result of theft, particularly of laptops and other portable electronic devices (www.hhs.gov/ocr/privacy/hipaa/ administrative/breachnotificationrule/postedbreaches.html retrieved 9/30/11). Psychologists should store backup media as carefully as they do their original electronic files. Retention of records Perhaps the most welcomed change in the guidelines’ revision is a shorter requirement to keep records. The guidelines state: “In the absence of a superseding requirement, psychologists may consider retaining full records until seven years after the last date of service delivery for adults or until three years after a minor reaches the age of majority, whichever is later.” As previously mentioned, psychologists must also consider any applicable state laws and other regulatory or institutional requirements in determining specific records retention policies. This guideline may be useful as psychologists prepare for retirement and plan for how records will be stored and later disposed of. The original rationale for disposing of records was to prevent “obsolete” clinical data from being misused in other contexts. Today, with electronic health records and the ability to store data in larger electronic systems, clinical information can be kept indefinitely. The Record Keeping Guidelines suggest that psychologists document the context in which the record is created, such as the reason for referral or evaluation, and specific circumstances impacting the client at the time of service. Professionals who review records at a later date also have the responsibility to recognize when clinical documents or testing results are obsolete or unduly prejudicial to current decision-making. In most cases, this is of greatest concern when the record creates a negative impression of the client. APA’s record keeping resources • Applying the APA Record Keeping Guidelines in Clinical Practice (webinar): www. apapracticecentral.org/flash/record-keepingguidelines/index.aspx. • APA Ethical Principles of Psychologists and Code of Conduct. • American Psychological Association. (2010). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010). retrieved from http://www.apa.org/ethics/code/index.aspx. • Health Information Technology: www. apapracticecentral.org/advocacy/technology/ index.aspx. • HIPAA Compliance: www.apapracticecentral. org/business/hipaa/index.aspx 73 http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/postedbreaches.html http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/postedbreaches.html http://www.apapracticecentral.org/flash/record-keeping-guidelines/index.aspx http://www.apapracticecentral.org/flash/record-keeping-guidelines/index.aspx http://www.apapracticecentral.org/flash/record-keeping-guidelines/index.aspx http://www.apa.org/ethics/code/index.aspx http://www.apapracticecentral.org/advocacy/technology/index.aspx http://www.apapracticecentral.org/advocacy/technology/index.aspx http://www.apapracticecentral.org/advocacy/technology/index.aspx http://www.apapracticecentral.org/business/hipaa/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