Record Keeping, Documentation, and Privacy Legislation
Records questions test PHIPA mechanics plus the College's documentation expectations. Both are examinable, and they are not identical.
PHIPA foundations
The psychologist is a health information custodian. Personal health information includes notes, test data, emails, billing details and voicemail - any format. Records must be accurate, legible, completed promptly, and stored securely. Access requests must be answered within 30 days, with a reasonable fee and a fee estimate where applicable; limited refusals are permitted, for example where disclosure would cause a risk of serious harm. Clients may request correction; if you disagree, attach a statement of disagreement.
Retention and custody
The College's record-keeping expectations require retention for at least ten years after the last professional contact, and for minors, ten years after the client reaches the age of majority. Records must be retained while a complaint, investigation or legal proceeding is open. On retirement or death, arrange for transfer or secure destruction; do not simply abandon files.
Privacy breaches
If personal health information is stolen, lost, or accessed or disclosed without authority, notify the Information and Privacy Commissioner and affected individuals without unreasonable delay, contain the breach, and document the incident and response.
Documentation content
Identify the client and date, the nature and purpose of contact, findings and observations, consent discussions, the plan, referrals, consultations, supervision, and any risk assessment. Write as if a colleague will one day rely on the note without you.
Worked example
An insurer demands the entire file. The client signed a form authorising release to the insurer. The psychologist checks the authorisation's scope, discloses only what the purpose requires (or confirms scope with the client), and records what was sent, to whom, and when. Broad consent forms do not authorise indiscriminate disclosure.
Traps that cost marks
- Treating rough notes as outside the record; they are part of it.
- Destroying records because a complaint feels resolved.
- Withholding an entire file because it contains third-party information instead of severing that portion.
- Assuming email, texts and voicemail are not personal health information.