Rule 510-5-.04 - Maintenance and Retention of Records(1) Records include information that may be used to document the nature, delivery, progress, and results of psychological services. The psychologist who renders professional services shall maintain records that include the following: (a) Records of psychological services include: 1. identifying data (e.g., name, client ID number);2. contact information (e.g., phone number, address, emergency contact);3. fees and billing information;4. where appropriate, guardianship or conservatorship status;5. documentation of informed consent or assent for treatment (Ethics Code 3.10);6. documentation of waivers of confidentiality and authorization or consent for release of information (Ethics Code 4.05);7. documentation of any mandated disclosure of confidential information (e.g., report of child abuse, release secondary to a court order);8. complaint, diagnosis, or basis for request for services;9. plan for services, updated as appropriate (e.g., treatment plan, supervision plan, intervention schedule, community interventions, consultation contracts);10. relevant health and developmental history;11. date of service and duration of session;12. types of services (e.g., consultation, assessment, treatment, training);13. nature of professional intervention or contact (e.g., type of treatment, referral, letters, e-mail, phone contacts);14. formal or informal assessment of client status.(2) Psychologists are aware of relevant federal state and local laws and regulations governing records. Laws and regulations supersede requirement of these rules. In the absence of such laws and regulations, psychologists maintain complete records for seven years after the last date of service delivery for adults. If the client is a minor, the record period is extended until three years after the age of majority, or at least for seven years after the last date of service delivery, whichever is later.(3) The psychologist shall store and dispose of written, electronic, and other records of patients and clients in such a manner as to ensure their confidentiality.Ga. Comp. R. & Regs. R. 510-5-.04
O.C.G.A. §§ 43-1-25, 43-39-5 and 43-39-6.
Original Rule entitled "License Renewal Fee" adopted. F. May 5, 1989; eff. May 25, 1989.Repealed: New Rule of same title adopted. F. June 25, 1993; eff. July 15, 1993.Repealed: New Rule entitled "Impairment and Dual Relationships" adopted. F. July 27, 1994; eff. August 16, 1994.Repealed: New Rule entitled "Maintenance and Retention of Records" adopted. F. Mar. 18, 2004; eff. Apr. 7, 2004.Repealed: New Rule of same title adopted. F. Mar. 20, 2008; eff. Apr. 9, 2008.Amended: F. Mar. 4, 2015; eff. Mar. 24, 2015.