CPLEE - CA Laws That Guide the Specifics of Clinical Practice: Treatment Records

CA law requires that a full set of treatment records be maintained on all patients for a minimum of ___ years after treatment has been completed.

As of January 1, 2007, the Business and Professions sCode (2919) requires that for minors, the treatment records be maintained for at least ___ years from the date the patient reaches ___ years of age (in other words, until the person is ___ years old).

The APA provides a different set of standards pertaining to keeping records that may be followed in the absence of superseding guidelines; APA’s Record Keeping Guidelines (2007) state that psychologists may retain a full set of records for adults for ___ years after the last date of delivery of service, and for minors they may retain records for either ___ years, or ___ years after the minor reaches the age of majority, whichever is later.

Psychologists must keep a record of each patient visit; at minimum, each note should contain:

Identifying data

Date of ____________

Type of service

__________ with patient

Fee

__________ status notation

Assessment of the patient in general terms

Plan for ______________

Patient records should also include:

Consultations

___________/_____________ reports

Releases of information

Providers using electronic record keeping must ensure the safety and integrity of the records by using:

An ____________________ system

An ____________________ that can copy signature documents

A mechanism to ensure that once input, data is ________________

Adult patients, parents/guardians of minors in treatment, minor patients who have been authorized by law to consent to treatment, and patient representatives are entitled to inspect and/or obtain a copy of treatment records after presenting a __________________.

Psychologists _____________ withhold patient records or summaries on the basis of an unpaid bill.

There are two circumstances under which a parent/guardian may be denied access to a minor’s treatment record:

If the minor was _________________ to get treatment by him/herself, the parent/guardian may be denied access to the record

CA law states that if the provider determines there could be a ___________________________, or that the minor’s ___________________ might be jeopardized, the parent or guardian may be denied access to the record

CA law states that patients generally have a right to inspect and/or obtain a copy of treatment records; however, a treatment provider may decline to permit inspection/provide copies if the provider believes there would be _______________________________________ to the patient.

HIPAA guidelines with regard to access to treatment records differ from CA law, and preempt CA law with regard to ___________, but not ___________.

HIPAA states that access to records can be denied only when the record ____________________________________.

The therapist must always permit the inspection of the records by or copy the records for other ________________________ designated by the patient.

The provider must generally permit inspection of the records within ___ working days after a written request is received. When inspecting the records, the patient or patient’s representative may be accompanied by ___ other person(s) of his/her choosing.

Copies of the treatment records (at a cost not to exceed $___ per page) must generally be transmitted within ___ days after receiving a written request. Providers are not allowed to withhold records because of any unpaid bills for services.

CA notes that the provider may offer to prepare a treatment summary for a patient; if the patient agrees, the summary should be completed within ___ working days. If extenuating circumstances exist (e.g., long treatment record), the provider must notify the patient of this and may take up to ___ days to deliver the summary.

A patient treatment summary should contain:

Chief complaints and pertinent history

Findings from ________________ with and ________________ to other health care providers

Diagnosis

__________ Plan and Rx prescribed

Progress of treatment

______________ and significant continuing problems

Reports of diagnostic procedures/tests

______________ summaries

Objective findings from recent physical exams

When a patient provides written authorization to release records to the BOP or a court order mandates release of records to the board, records must be provided within ___ days. The civil penalty, payable to the board, is $__________ per day for each additional day the documents haven’t been provided, after the ___th day.

Failure to comply with a court order mandating the release of records to the BOP constitutes unproffesional conduct and may result in __________________ or __________________________.