Client records

Clear and accurate client records are essential to quality services and good governance, and their form depends on the service, setting and legal and organisational requirements. Effective practice still means the psychologist: (a) keeps records that are accurate, current, factual, objective, legible and accessible and that capture the relevant details of the service in a way other practitioners and colleagues can follow; (b) keeps records secure from unauthorised access and protects the integrity and privacy of electronic records (section 3.3); (c) keeps records respectful of clients and associated parties and free of demeaning or derogatory remarks; (d) makes records sufficient for the service to continue; (e) writes records when events occur or as soon as possible after; (f) promptly arranges transfer or management, disposal included, of client information under the relevant law when a client asks or the work setting closes or moves; and (g) keeps client information as legislation or the organisation requires and for no less than (i) seven years after the last entry for an adult client, and (ii) until the client turns 25 where the client was under 18 at the last entry.

• Sample of client files audited for accuracy, timeliness, legibility and respectful language
• Records retention schedule meeting the seven-year adult minimum and age-25 minor minimum, plus state health records law
• Records system security settings, backup and audit trail
• Log of transfer and disposal of client records with dates and authority

• Notes written days after sessions
• Minor's records destroyed seven years after the last entry, before the client turned 25
• Judgemental language about clients in notes
• Records on personal devices without security controls