Client Records

(1) Purposes – The purposes of these rules are: (a) To recognize that client records are an integral part of the practice of applied behavior analysis as defined in T.C.A. § 63-11-310 and the respective certifying entity’s Ethical Code. (b) To give licensed behavior analysts and licensed assistant behavior analysts, their professional and non-professional staff, and the public direction about the content, transfer, retention, and destruction of those records. (2) Client Records – (a) Duty to Create and Maintain Client Records – As a component of the standard of care and of minimal competency a licensed behavior analyst and licensed assistant behavior analyst must cause to be created and cause to be maintained a record for every client for whom he or she, and/or any of his or her professionally certified supervisees, performs services or provides professional consultation. (b) Content – All client records, or summaries thereof, produced in the course of the practice of applied behavior analysis for all clients shall include information that is necessary to ensure that a subsequent reviewing or treating licensed behavior analyst or licensed assistant behavior analyst can both ascertain the assessment and analysis and provide continuity of care for the client. (c) Transfer – 1. Records of Licensed Behavior Analysts and Licensed Assistant Behavior Analysts Upon Death or Retirement - When a licensed behavior analyst or licensed assistant behavior analyst retires or dies while in practice, clients seen during the immediately preceding eighteen (18) months shall be notified by the licensee’s authorized representative and be informed that upon authorization, copies of the records will be transferred to the new provider chosen by the client. This notification requirement shall not apply to a client when there have been fewer than two (2) client encounters within the immediately preceding eighteen (18) months. 2. Records of Licensed Behavior Analysts and Licensed Assistant Behavior Analysts Upon Departure from a Group - The responsibility for notifying clients of a licensed behavior analyst or licensed assistant behavior analyst who leaves a group practice whether by death, retirement or departure shall be governed by the employment contract of the licensed behavior analyst or licensed assistant behavior analyst. (i) The individual who is responsible for the employment contract must notify clients seen by the licensed behavior analyst or licensed assistant behavior analyst during the immediately preceding eighteen (18) months of his/her departure, except that this notification requirement shall not apply to a client when there have been fewer than two (2) client encounters within the immediately preceding eighteen (18) months. (ii) Except where otherwise governed by provisions of the employment contract, those clients shall also be notified of the practitioner’s new address and offered the opportunity to have copies of their records forwarded to the departing licensed behavior analyst or licensed assistant GENERAL RULES GOVERNING THE PRACTICE OF LICENSED BEHAVIOR CHAPTER 1180-05 ANALYSTS AND LICENSED ASSISTANT BEHAVIOR ANALYSTS behavior analyst at his or her new practice. Provided however, a group shall not withhold the records of any client who has authorized their transfer to the departing licensed behavior analyst or licensed assistant behavior analyst or any other practitioner. (iii) The choice of practitioner in every case should be left to the client, and the client should be informed that upon authorization his/her records will be sent to the licensed behavior analyst or licensed assistant behavior analyst of the client’s choice. 3. Sale of an Applied Behavior Analyst Practice – A licensed behavior analyst or licensed assistant behavior analyst or the estate of a deceased licensed behavior analyst or licensed assistant behavior analyst may sell the elements that comprise his/her practice, one of which is its goodwill, i.e., the opportunity to take over the clients of the seller by purchasing the client records. Therefore, the transfer of records of clients is subject to the following: (i) The licensed behavior analyst or licensed assistant behavior analyst (or the estate) must ensure that all client records are transferred to a licensed behavior analyst or licensed assistant behavior analyst. (ii) Clients seen by the licensed behavior analyst or licensed assistant behavior analyst during the immediately preceding eighteen (18) months shall be notified that the licensed behavior analyst or licensed assistant behavior analyst (or the estate) is transferring the practice to another practitioner or entity who will retain custody of their records and that at their written request the copies of their records will be sent to another practitioner or entity of their choice. This notification requirement shall not apply to a client when there have been fewer than two (2) client encounters within the immediately preceding eighteen (18) months. 4. Abandonment of Records – For purposes of this section of the rules, death of a licensed behavior analyst or licensed assistant behavior analyst shall not be considered as abandonment. It shall be a prima facie violation of T.C.A. § 63-11- 310(2)(D) for a licensed behavior analyst or licensed assistant behavior analyst to abandon his practice without making provision for the maintenance, security, and access to client records. (d) Retention of Client Records – Client records shall be retained for a period of not less than seven (7) years from the last clinical contact between the client and the licensed behavior analyst or licensed assistant behavior analyst, except for the following: 1. Records for incompetent clients shall be retained indefinitely. 2. Records of minors shall be retained for a period of not less than one (1) year after the minor reaches the age of majority or seven (7) years from the date of the last clinical contact with the client, whichever is longer. 3. Notwithstanding the foregoing, no client record involving services which are currently under dispute shall be destroyed until the dispute is resolved. (e) Destruction of Client Records – 1. No client record shall be singled out for destruction other than in accordance with established office operating procedures. GENERAL RULES GOVERNING THE PRACTICE OF LICENSED BEHAVIOR CHAPTER 1180-05 ANALYSTS AND LICENSED ASSISTANT BEHAVIOR ANALYSTS 2. Records shall be destroyed only in the ordinary course of business according to established office operating procedures that are consistent with these rules. 3. Records may be destroyed by burning, shredding, or other effective methods in keeping with the confidential nature of the records. 4. When records are destroyed, the time, date and circumstances of the destruction shall be recorded and maintained for future reference. (3) Violations – Violation of any provision of these rules is grounds for disciplinary action pursuant to T.C.A. § 63-11-310(2)(D).