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Disclaimer: Law, rules and regulations, not Guidelines, specify the requirements for practice and violating them constitutes professional misconduct. Not adhering to this Guideline may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations.

Guideline 4: Documenting the Provision of Services

You should maintain written records related to all substantive contact with patients and the records should be kept in a secure setting. If you choose to keep electronic records, you should make a backup copy that is kept in a secure setting.

While the content and format of patient records is not prescribed in the law or regulations, you must maintain a record that indicates the assessment and treatment of each patient. There is general consensus that an acceptable record includes:

  • patient name and contact information;
  • reason for initial contact, preliminary assessment, and subsequent disposition;
  • comprehensive assessment of problem, including reasons to support the assessment;
  • history of treatment for same or related condition, including any medical evaluations and prescriptions if appropriate;
  • plan for service;
  • dates of service and issues of significance discussed during each contact with patient, including specific actions to be taken related to those issues, if relevant;
  • discharge summary, including specific notation of any plans for future treatment and/or referral or circumstances under which a patient stops using services against your advice or because you are leaving the agency and/or practice (see Guideline 1);
  • specific steps taken at any time during the course of service to assess and treat issues of potential danger to the patient and/or others, such as suicide or homicide, or the suspected abuse or neglect of a child; and
  • any consultations with other professionals, including reason for consult and outcome, and patient's authorization to release information.

Maintain all paper and electronic patient records in a secure area accessible only to authorized persons in accordance with applicable State and federal laws and regulations and in a manner that lends itself to substantiating the records to be trustworthy and unalterable.

Be aware of retention requirements for patient records, including the period you are required to retain records by law. You should plan to retain records for a longer period, when necessary, such as a patient with a long-term condition whose treatment will continue beyond the statutory requirement. You must keep records for 6 years or until the patient turns 22 years of age, which ever is longer.

You should be familiar with requirements for providing patient access to records. For instance, New York State public health law requires that you provide a patient with copies of his or her records, upon request, and may charge no more than 75 cents per page for copying the records.

Citations of Pertinent Law, Rules or Regulations: