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Professional records - 49 Pa. Code § 41.57

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Psychologists must maintain a record for each client, which includes, at a minimum:

  • The name and address of the client/patient and, if the client/patient is a minor, the names of the parents or the name of the legal guardian. If a minor’s parents are separated, notation of legal custodial arrangements is required;
  • The presenting problem or purpose or diagnosis;
  • The date and substance of each service contact;
  • Test results or other evaluative results obtained and basic test data from which they were derived;
  • Notation and results of formal consults with other providers;
  • A copy of all test or other evaluative reports prepared as part of the professional relationship; and
  • Authorizations, if any, by the client/patient for release of records or information.

The psychologist must store and dispose of records in a manner which insures its confidentiality.  Additionally, the psychologist should assure that all data entries are maintained for at least 5 years after the last date the service was rendered.

Current as of June 2015