Professional records - 49 Pa. Code § 41.57

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.