California Law On Record Keeping and Records Retention
This document is also a part of an online course and focuses on the application of California Law to record keeping.
The most relevant codes of ethics for California psychologists, MFTs and LCSWs are the APA, CAMFT and NASW, respectively. For information on these and other codes on record keeping, go to http://www.zurinstitute.com/ethicsofrecordkeeping.html.
California Laws and Regulations Relating to the Practice of Psychology
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
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 ten years prior to the date of disposing of the records.
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.
The rational for the ten years old is the following: The general recommendation by CAMFT and other organizations is at least seven years, and better yet, ten years. That recommendation is based on the standard established for hospitals and community treatment facilities. Additionally, since the BBS can pursue disciplinary actions for up to seven years (see below), keeping records for that period makes sense. The seven years rule is also consistent with AB 2257 law for psychologists (starting Jan. 1, 2007). The only exception is in the case of an allegation of sex (see below), which is ten years, thus why ten years might be better.
Please note that there may be forensic or other reasons to keep records longer.
Contact BBS, CAMFT or CA-NASW for updates and verification.
Additional Information of California Law Regarding Records Retention
California Health and Safety Code Section 1795.26: This code requires records to be maintained for a minimum of seven years following the discharge of a client from certain clinics, including nonprofit psychological clinics. In the case of minors where 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).
BOARD OF BEHAVIORAL SCIENCES-LAWS AND REGULATIONS RELATING TO THE PRACTICE OF MARRIAGE AND FAMILY THERAPY, LICENSED CLINICAL SOCIAL WORK, AND LICENSED EDUCATIONAL PSYCHOLOGY (p. 33): (http://www.bbs.ca.gov/pdf/publications/lawsregs.pdf )
§4982.05. ENFORCEMENT STATUTE OF LIMITATIONS (a) Except as provided in subdivisions (b), (c), and (e) any accusation filed against a licensee pursuant to Section 11503 of the Government Code shall be filed within three years from the date the board discovers the alleged act or omission that is the basis for disciplinary action, or within seven years from the date the alleged act or omission that is the basis for disciplinary action occurred, whichever occurs first.
(e) An accusation filed against a licensee pursuant to Section 11503 of the Government Code alleging sexual misconduct shall be filed within three years after the board discovers the act or omission alleged as the ground for disciplinary action, or within 10 years after the act of omission alleged as the grounds for disciplinary action occurs, whichever occurs first. This subdivision shall apply to a complaint alleging sexual misconduct received by the board on and after January 1, 2002.
Business and Professional Code §123145: Preservation of records after licensee ceases operation; Action for abandonment of records:
Providers of health services that are licensed pursuant to Sections 1205, 1253, 1575 and 1726 have an obligation, if the licensee ceases operation, to preserve records for a minimum of seven years following discharge of the patient, except that the records of unemancipated minors shall be kept at least one year after the minor has reached the age of 18 years, and in any case, not less than seven years.
Specific Board of Psychology (BOP) guidelines for record keeping: Source: http://www.psychboard.ca.gov/pubs/bop-1097.pdf
1 . Article by The former chair of BOP, Bruce Ebert, Ph.D., J.D., on Record Keeping on pages 1 & 11. 2. Article titled Record Keeping and Disposal on pages 2 & 3.
To receive clinical and practice updates, add your name to our confidential e-mail list. CLICK HERE
