Record keeping guidelines.
These guidelines are designed to educate psychologists and provide a framework for making decisions regarding professional record keeping. State and federal laws, as well as the American Psychological Association's "Ethical Principles of Psychologists and Code of Conduct," generally require maintenance of appropriate records of psychological services. The nature and extent of the record will vary depending upon the purpose, setting, and context of the psychological services. Within these guidelines, more directive language has been used when a particular guideline is based specifically on mandatory provisions of the Ethics Code or law. However, some areas are not addressed in those enforceable standards and regulations. In these areas, more aspirational language has been used. This document aims to elaborate and provide assistance to psychologists as they attempt to establish their own record keeping policies and procedures.
American Psychological Association.
D004282:Documentation / Q000379:methods* / Q000592:standards*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D012958:Societies, Scientific; D014481:United States