Disposing of Clinical Records in California
Forward this important information of the upcoming changes to fellow California psychologists, MFTs and LCSWs.
Clinical Update September 2006
By Zur Institute
For a complete list of all Clinical Updates, click here.
California Psychologists: Rev up the Shredders --
New Record Keeping Regulations for California Psychologists
Beginning January 1, 2007, all licensed psychologists in California must retain a patient's health service records for a minimum of seven (7) years from the patient's discharge date or seven years after a minor patient reaches the age of eighteen.
California Governor, Arnold Schwarzenegger, signed AB 2257 on July 20, 2006.
This provides much needed clarity, as prior to the passage and signing of AB 2257, state law did not address the issue of record retention by psychologists in independent practice.
The new requirement represents a minimum requirement for the length of time psychologists must retain mental health records. The implication is that each case must be considered individually to determine if there is a reasonable basis for retaining the records longer.
Private practitioners are allowed to retain their records for a longer period, if they wish or are required to.
The new law means that on January 1, 2007, California psychologists can dispose, preferably by shredding or incineration, records of adult clients whose treatments were terminated prior to December 31, 1999.
The new requirement is consistent with current practice for California's heath facilities, such as licensed clinics, nursing facilities, adult day health care facilities, intermediate care facilities and skilled nursing homes.
Florida, New Jersey and Oregon have equivalent record retention requirements of seven years minimum from last appointment or date of service. Texas has a longer retention of records with a minimum of ten years and an additional ten years after the patient turns eighteen.
Until January 1, 2007, California psychologists should continue to retain full records for three years after completion of planned services or after the last date of contact. Full or summary records are to be retained for an additional twelve years. The record may be disposed of no sooner than fifteen years after completion of planned services or after the date of the last contact, whichever is later. In the case of minors, the records shall be kept at least one year after the minor has reached the age of 18, but in no case less than seven years.
Please note that there may be forensic or other reasons to keep records longer.
California MFTs and LCSWs: No Changes to Existing Laws
The recommendation for record keeping for California MFTs and LCSWs: Taking into consideration §4982.05, Enforcement Status Limitation code, and the changes instituted in 2004, the recommendations are:
Records created by marriage, family and child counselors and social workers should be preserved for a minimum of ten (10) years following the discharge of the patient.
That means that California MFTs and LCSWs can dispose, preferably by shredding or incineration, records of adult clients whose treatments were terminated prior to October, 1996.
Records of un-emancipated minors should be kept one year after the minor has reached the age of majority but in no event less then 10 years.
Please note that there may be forensic or other reasons to keep records longer.
Contact BBS, CAMFT or CA-NASW for updates and verification.
