Academic journal article Canadian Psychology

An Updated Account of the Ethical and Legal Considerations of Record Keeping

Academic journal article Canadian Psychology

An Updated Account of the Ethical and Legal Considerations of Record Keeping

Article excerpt

The Canadian literature is void of contemporary guidelines for clinical record keeping for psychologists, as the most recent article was published more than two decades ago (Eberlein, 1990). However, the techniques used in record keeping have greatly advanced, specifically with regard to the role of computers and the use of electronic documents. Furthermore, new legislation and guidelines have been developed in response to these technological advancements. The purpose of this article is to provide a concise, accessible, and up-to-date set of guidelines on record keeping in psychology. The professional and legal requirements of psychologists are discussed with regard to the use, content, access, ownership, and retention of records with special consideration given to electronic documents. Recommendations are made for Canadian psychologists that are consistent with the current legal and professional standards of the field.

Keywords: record keeping, client files, electronic documents, Code of Ethics

The Canadian literature is void of contemporary guidelines for clinical record keeping. Although books that contain information regarding record keeping have been published more recently (e.g., Evans, 2004 and Truscott & Crook, 2004), the most recent article dates back to 1990 (Eberlein, 1990). Eberlein's article was written largely in response to the establishment of the Canadian Code of Ethics for Psychologists (Canadian Psychological Association [CPA], 1988; herein referred to as the Code of Ethics). However, two revisions of the Code of Ethics have been published (1999 and 2001), and the techniques used in record keeping have advanced, specifically with regard to the role of computers and the use of electronic documents. Beyond the above developments, the federal Personal Information Protection and Electronic Documents Act (PIPEDA) was introduced in 2000, and it has modified the statutes relevant to records. Similarly, a draft of guidelines for psychologists who provide psychological services via electronic media was developed (CPA, 2006; to be finalized). The American Psychological Association (APA) set forth guidelines for record keeping in 2007 that address many of the issues surrounding client files, but the CPA is yet to develop a comprehensive document devoted to record keeping.

The purpose of this article is to provide a concise and accessible resource on record keeping that is up-to-date with the advances that have occurred since 1990. This article provides a comprehensive overview of the issues related to record keeping and provides recommendations for Canadian psychologists. More specifically, the professional and legal requirements of psychologists are discussed with regard to the use, content, access, ownership, and retention of records with special consideration given to electronic documents. The implications of technological advances on client confidentiality and privacy are also considered.

The suggestions made in this paper are consistent with the Code of Ethics, as well as legislative and provincial laws and regulations, including the Code of Conduct (or its equivalent) of each province and territory. While the Code of Ethics is aspirational in the principles, values, and standards it sets forth for psychologists, laws and codes of conduct outline minimally acceptable standards of behaviour for all members of society and professionals, respectively. Failure to follow the Code of Ethics, as well as the legislative laws and regulations, can result in professional negligence, or even criminal or civil liability. The serious nature of improper record keeping highlights the importance of an up-to-date document on the creation, use, and maintenance of client files, especially in light of the confusion noted by Evans (2004) on the chaotic legislation governing access to and the protection of health information in Canada.

Although similarities prevail in the provincial legislations related to record keeping, psychologists are expected to be familiar with the requirements specific to their province or territory (see Table 1). …

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