Professional Documents
Culture Documents
What Canadian & Provincial Codes of Ethics and Standards of Practice Have to Say
Opening Vignette Introduction: Importance of Record Keeping Discussion of Record Keeping Codes/Standards of Practice
Content ~ Vignette Privacy, Confidentiality & Access ~ Vignette Storage & Transfer ~ Vignette Retention ~ Vignette Ownership ~ Vignette
Outline of Presentation
You are currently living in Calgary, working as a School Psychologist for a local School District where you maintain the records of all your clients. You are moving to Vancouver to open your own private clinic as a Psychologist.
Are you responsible to take records with you? Do you leave your Records with the District? If so, how long do you keep the records you have kept? If you bring your records to B.C., which Provincial legislation will the retention of your records fall under?
Vignette
Benefit to Client Documentation of treatment plans Documentation of services provided Documentation of client progress Protection in the event of legal proceedings
Introduction
(APA, 2007)
Benefit to Psychologist Documentation of planning Documentation of interventions, courses of action Allows for self-monitoring, accountability Important when there is a large delay in treatment or when transferring services to another professional Protection in the event of legal proceedings
Introduction
(APA, 2007)
National Provincial
Local
Governing Standards
Know before you start Advocate for change Follow the Code
Governing Standards
(Drogin et al, 2010)
To provide good care To assist & collaborate with other professionals To ensure continuity of services For supervisory or training needs For reimbursement or under contract For effective decision making To answer legal or regulatory complaints
Content
( APA, 2007)
What is required to be included What is required to not be included Juvenile records, HIV test results Client wishes Context different expectations for emergency, disaster relief Requirements of third-party payers Referral needs and usage Balance obligations with level of risk
Content
( APA, 2007; Drogin et al, 2010)
GENERAL CONTENT OF RECORDS Seek and collect, with the clients consent, documented, relevant information from reliable sources.
CA AB BC NS ON
Content: General
SPECIFIC CONTENT. Records should include the following: Appropriate identifying information. BC name
AB BC NS ON
Content: Specific
SPECIFIC CONTENT. Records should include the following: A copy of all documents relied upon in the course of providing psychological services
AB BC NS ON
Date of every relevant and clinically significant contact with the client.
Information regarding services that were started, but not completed, and an explanation of why. Information on all referrals to other professionals. Ensure all entries are dated and that the identity of the person making the entry is noted. NOT required to keep information on persons receiving prevention, public education, group training, emergency or post-emergency group services or group screening services.
Content: Specific
AB BC NS ON
Payer
Recipient of professional services Date, nature and unit fee of the service provided Total charged Payment received Date of payment Source of payment Other information that the client may need to obtain insurance reimbursement
You tend to be a bit of a hoarder and you have neglected to keep your file information organized you need to cull your files before you move and keep only necessary information.
What absolutely needs to be in your files?
Content: Vignette
Must meet governing standards Necessary to promote trust Conflicts guided by The Code
Access:
Best practice: Assume at some point any client may ask to access his or her (or their childs) records Best practice: Understand and communicate third-party access obligations up front (school personnel, insurance)
Privacy, Confidentiality & Access to Records Maintain privacy and security all of records, including during collection, storage, handling and transferring of information. Ensure clients, or parents of minor clients, have appropriate access to their records. Ensure school records are not released to persons or agencies outside the school without parent consent, unless required or permitted by law. Only allow school personnel who have a legitimate educational interest access to school psyc records, unless specific consent is given. Only collect and record information necessary to respond to the needs of the client. Ensure information from records is not used to violate a clients rights or privacy. Develop procedures to allow clients to correct errors in their records.
CA AB BC NS ON
CA AB BC NS ON
You just nicely get settled in Vancouver when you get a letter from McInnis Barristers and Solicitors. A family of a Special Needs child in your Calgary district is suing your old District. They claim that the confidentiality of their childs private information was jeopardized in your district. The legal firm is requesting that you forward your file to them so they can investigate. You begin to reflect on your practice did you ensure confidentiality at all times? What best practice should you have been using to ensure confidentiality and student privacy?
Storage and Transfer of Records Develop methods that are logical and consistent Best practice: Create separate sections in files that may be accessed by others to ensure they only access applicable sections Have back-up system in place before it is needed!
Storage and Transfer of Records Parents and clients have a right to understand how records are stored and maintained, and any associated risks to privacy. Protect records from unauthorized release. Safeguard any loss of records. Advocate for district policies that safeguard security, allow appropriate access, provide for periodic review, dispose of records responsibly. If using an organization-wide record-keeping system, be responsible to control and safeguard their portion of record. Store and dispose of records in a manner that ensures confidentiality and security. Design electronic systems to guard against loss, tampering, interference, or unauthorized use or access.
CA AB BC NS ON
You have packed everything up your life is in boxes! You have got quotes from two moving companies: Big Bad Bills moving (he lives down the street, does moving on the side, and will move you to B.C. for less than you could rent a U-Haul for). North America Moving Company (a large company who is bonded and guaranteed secure but more than triple the cost of Big Bad Bill!)
Does it matter who you move your belongings with? It is you who is footing the bill!
Consider:
Differences between provinces What circumstances may require retention of records beyond the minimum time frame How to track and dispose of records no longer needed (confidentiality!)
Retention
Retention Must maintain records for at least 10 years after date of last professional service. Must maintain records for at least 7 years after date of last professional service. Must maintain minor records for at least 7 years after minor reaches age of majority. Must maintain minor records for at least 10 years after the minors 18th birthday. Supervisory records must be kept for a minimum of 7 years after the date of last supervised activity.
CA AB BC NS ON
Retention
You pull out the childs file and you notice that the last time you had contact with the special needs child in question was November 2nd, 2000. Legally, do you still need to retain the file? Does the fact that you are now in B.C. and the child is in Alberta have any bearing in this dilemma, given that B.C. and Alberta clearly have different retention laws?
Retention: Vignette
Ownership:
Know before you start! Communicate with your client Have a plan
Ownership
Ownership Have adequate contingency plans in place for what to do with records in case of own serious illness, change of employment or death. Before retiring ensure primary responsibility is transferred to another qualified professional &that this transfer is communicated to the College Before retiring ensure clients are notified in a timely manner and given the opportunity to obtain their own copies of their client record or have records transferred to professional of their choice
CA AB BC NS ON
Ownership
With the latest law suit surfacing, you decide it is time to retire.
What best practice safeguards do you now put in place when anticipating your impending retirement?
Ownership: Vignette
American Psychological Association. (2007.) Record keeping guidelines. American Psychologist, 62 (9), 993-1004. Retrieved from http://www.apa.org/practice/guidelines/record-keeping.pdf BC Association of School Psychologists. (2010). Ethical conduct and professional practice. Vancouver: Author. Retrieved from http://www.bcasp.ca/cms_pdfs/Ethics%20March%202010.pdf Canadian Psychological Association. (2000) Canadian code of ethics for psychologists (3rd ed). Ottawa: Author. Retrieved from http://www.cpa.ca/cpasite/userfiles/Documents/Canadian%20Code%20of%20Ethics%20for%20Ps ycho.pdf Canadian Psychological Association. (2001). Practice guidelines for providers of psychological services. Ottawa: Canadian Psychological Association. Retrieved from http://www.cpa.ca/cpasite/userfiles/Documents/publications/Practice%20Guidelines2001%282% 29.pdf College of Alberta Psychologist. (2000). Code of conduct. Edmonton, AB: Author. Retrieved from http://library.athabascau.ca/caap603/codeofconduct.pdf
References
College of Alberta Psychologists. (2005). Control and use of tests by psychologists. Edmonton, AB: Author. Retrieved from http://www.cap.ab.ca/pdfs/HPAPGFP-ControlandUseofTests.pdf College of Alberta Psychologists. (2005). Standards of practice. Edmonton, AB: Author. Retrieved from http://www.cap.ab.ca/pdfs/HPAStandardsofPractice.pdf College of Psychologists of BC. (2009) Code of conduct. Vancouver, BC: Author. Retrieved from http://www.collegeofpsychologists.bc.ca/documents/Code%20of%20Conduct%202009%20full%2 0page%20version.pdf Drogin, E.Y., Connell, M., Foote, W.E., Sturm, C.A. (2010). The American Psychological Associations revised Record Keeping Guidelines: Implications for the practitioner. Professional Psychology: Research and Practice, 41 (3), 236-243. National Association of School Psychologists. (2010) Principles for professional ethics. Bethesda, MD: Author. Retrieved from http://www.nasponline.org/standards/2010standards/1_%20Ethical%20Principles.pdf
References
Nova Scotia Board of Examiners in Psychology. (2007) Standards of practice. Halifax, NS: Author. Retrieved from http://www.nsbep.org/downloads/Binder_Standards_Legislation_Guidelines.pdf The College of Psychologists of Ontario. (2005). Standards of professional conduct. Toronto, ON: Author. Retrieved from http://www.cpo.on.ca/assets/60F48DEF-3513-490F-B502FD46ADA6B78A.pdf
Truscott, D. & Crook, K. (2004). Ethics for the practice of psychology in Canada. Edmonton, AB: University of Alberta Press
References