868 IAC 1.1-11-4.2 Record keeping; discontinuation of practice

Sec. 4.2. (a) A psychologist shall keep accurate, current, and pertinent records of psychological services that are rendered or performed. Clinical records shall be maintained intact for a minimum of seven (7) years. These records shall include at least the following: (1) Identifying data. (2) Dates of services. (3) Types of services. (4) Significant actions taken. The records shall be made within a reasonable time after the rendering of the service. (b) A psychologist shall give a truthful, candid, and reasonably complete account of the patient's or client's condition to the patient or client or to those responsible for the care of the patient or client. Patients or clients shall be kept fully informed as to the purpose and nature of any evaluations, treatments, or other procedures and shall retain full freedom of choice with regard to participation in and the receipt of psychological services. (c) Information in patient or client records is confidential and shall not be disclosed without the patient's or client's written permission unless disclosure is required by law. All persons having legitimate access to records shall maintain the confidentiality of the records. (d) Access to patient or client records shall be provided in accordance with IC 16-39. (e) Information obtained in the professional relationship with a patient or client is confidential and shall not be disclosed in any way by the psychologist without the patient's or client's written permission unless disclosure is required by law. (f) Upon discontinuation of the practice of psychology, a psychologist shall notify all active patients or clients in writing and by publication once a week for three (3) consecutive weeks in a newspaper of general circulation in the community of the intention to discontinue practice and shall encourage the patients or clients to seek the services of another psychologist or other professional. The psychologist shall make reasonable arrangements with the patients or clients for the transfer of the records, or copies, to the succeeding practitioner. As used in this subsection, "active patient or client" refers to any patient or client with whom the psychologist has consulted within the two (2) year period prior to retirement or discontinuation of practice.