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California Law On Record Keeping and Records Retention

By Ofer Zur, Ph.D.
 

This article is part of an online course for 6 CE Credits (CEUs) on
Record Keeping in Psychotherapy: Ethical, Legal and Clinical Issues

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 www.zurinstitute.com/ethicsofrecordkeeping.html.

 

California Laws and Regulations Relating to the Practice of Psychology

Business and Professional Code of California

  1. Psychologists: Chapter 6.6
  2. MFTs: Division 2, Chapter 13, Article 1-7, Sections 4980 through 4989.
  3. LCSWs: Division 2, Chapter 14, Articles 1-4, Sections 4990 - 4998.7.

For regulations online:

 
Summary of CA Regulations on Records Retention

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.
  • The CA 2009 Laws and Regulations p. 32 states:
    Retention of Health Service Records: 2919. A licensed psychologist shall retain a patient's health service records for a minimum of seven years from the patient's discharge date. If the patient is a minor, the patient's health service records shall be retained for a minimum of seven years from the date the patient reaches 18 years of age.
  • 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 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.
  • This law means that as of 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 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.
  • Please note that there may be forensic or other reasons to keep records longer.

 
California MFTs and LCSWs

Here is CA law on the topic of record keeping (highlights in red are ours)

For more info, see §4993. CLIENT RECORDS: RETENTION (for LCSW in CA) and §4980.49. CLIENT RECORDS: RETENTION at http://www.bbs.ca.gov/pdf/publications/lawsregs.pdf p. 76:

§4993. CLIENT RECORDS: RETENTION

  1. A licensed clinical social worker shall retain a client’s or patient’s health service records for a minimum of seven years from the date therapy is terminated. If the client or patient is a minor, the client’s or patient’s health service records shall be retained for a minimum of seven years from the date the client or patient reaches 18 years of age. Health service records may be retained in either a written or an electronic format.
  2. This section shall apply only to the records of a client or patient whose therapy is terminated on or after January 1, 2015.

CAMFT info on record keeping can be found here.

California’s New Record Retention Law for LMFTs

Under California law, it is unprofessional conduct to, "[Fail] to keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services being rendered."1 Under California’s new record retention law, LMFTs are required to do the following:

  1. Retain a patient’s health care service record for a minimum of seven (7) years from the date therapy terminates;
  2. Retain a minor patient’s health care service record for a minimum of seven (7) years from the date the minor patient reaches eighteen (18) years of age; and,
  3. Maintain the record in either electronic or written form.

The law applies only to the records of a patient whose therapy terminates on or after January 1, 2015.

 
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