Running head: RECORD KEEPING 1

A Psychologists Ethical Look at Record Keeping Jo Friesen Angela Chiasson and Debby Kenna

University of Calgary, Alberta August 10, 2010

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Jo Friesen, Angela Chiasson and Debby Kenna collaborated to present the topic of Record Keeping to our cohort. In this paper you will find: 1) a brief outline of our presentation including discussions surrounding some of the issues raised during the presentation, 2) comments on further research, and 3) individual reflections from each presenter regarding a positive area and an area of further work that we noticed after our presentation was completed. In our presentation we discussed the topic of record keeping. We compiled and presented information according to the provinces in which members of our cohort reside. We considered National, Provincial and Local expectations of the following areas: necessary record/file content; privacy, confidentiality and accessibility issues; storage and transferability issues of file records; file retention expectations; and ownership of records. It was noted that a comprehensive look at all three levels is very much needed and should be shared especially to new psychologists entering the profession. There are common vital pieces of information that we must ensure are part of our records. Personal information such as name, birth date, medical history etc. must all be included. Records must also contain any protocols that were used in our assessments, all results and reports, fee arrangements (if applicable), the date and substance of each professional visit or service, and all releases and consents. One of the issues raised during our presentation was the issue of verbal consent. According to the Code, verbal consent is considered ethical; however, we must document any such consent in our files along with the date, and the length and details of the conversation. We also looked at the importance of abiding by confidentiality standards and access limitations. Electronic information must be encrypted, and confidentiality according to the Code

Running head: RECORD KEEPING 3 must be adhered to. All paper files must be kept under lock and key, in a locked room as well as a locked filing cabinet. Discussions were given to the fact that the roles of a psychologist compared to a school psychologist are different, and as such, the issues around confidentiality and access vary as well. Much of the information we gather must not be shared with school staff and it is the school psychologists responsibility to make sure that people are not accessing what they should not be accessing. This led to the importance of organizing files in such a way as to keep certain portions of the records separate, to ensure those who should have access to only some information did not have access to additional information they were not cleared for. We have the right to protect the confidentiality of our clients and as such retain the right to maintain our own file system with private, confidential information therein. We then discussed storage and transferability issues. It is our responsibility to ensure that the storage and transferability of files occur correctly and according to the provincial guidelines of the province in which the service was rendered. This includes explaining the storage procedures, and any associated risks to privacy to clients (and parents of minor clients), as well as ensuring a reliable back-up system is in place. The importance of investigating and becoming aware of these requirements before services are rendered is vital so that we can implement the best procedures for our practice. Retention rules vary at the Provincial level, which means that, as psychologists, we must be responsible to research provincial guidelines and adhere to the requirements. For example, British Columbia requires files to be stored for 7 years after the last professional service, whereas Alberta, Nova Scotia and Ontario require them to be kept for 10 years after that date. If we are assessing minors, the retention period begins from the point in time wherein they become adults.

Running head: RECORD KEEPING 4 Ownership has a variety of levels, and again varies from a psychologist to a school psychologist. A school psychologists files belong to the district; however, we must keep copies of our records as well. We must have contingency plans in place for what needs to be done with our files upon illness, death or change of employment. Upon retirement we must pass on our files to a responsible, qualified professional, communicate this transfer to the college, and inform clients of the transfer in case they would like a copy of their file, or to arrange transfer to another psychologist. Collaboratively, we discussed further research and the possibilities therein. A comprehensive analysis of Canada, province by province, could be conducted and compiled. For our presentation, we analyzed the provinces that our cohort represented; however, a Canadianwide analysis would be beneficial particularly for new psychologists in the field. Discrepancies between individual School Districts, National and Provincial levels and the Code of Conduct could be researched and used to facilitate action and change. As a professional body, our goal must be to follow our Code of Conduct in all circumstances. Discrepancies exist, and researching these discrepancies is the first step towards advocating change. Individually, each presenter spent time reflecting on both the positive aspects of our presentation as well as what we could improve upon if given the opportunity to present again. Although the following segments were written by individual team members, each excerpt is written in third person so the reader can identify the speaker. As Debby reflected upon her presentation, one of the first things she noted was how different on-line presentations were. Given that communication is significantly non-verbal, Debby commented that presenting in such a way was difficult to read and accurately respond accordingly to the audience in order to make it engaging. There was no way to tell if they were

Running head: RECORD KEEPING 5 truly enjoying the presentation and engaging in it, as there was no opportunity for eye contact and body language communications. She also commented that she found it surprising to experience just how nervous she was, despite the fact that she did not have a classroom of people in front of her. Debby felt that her decision to use one vignette and simply spin different questions and scenarios around the initial vignette was a positive decision, as this reflected just how deep the topic of record keeping can be in our professional lives. In addition, Debby felt that her vignette was applicable to all future psychologists, and the applicable situations provided an entertaining vehicle for a review of the material that the team had researched and that Jo was presenting to the cohort. Debby felt that her segment was fun, lively, practical and engaging for her classmates. One of the areas that Jo felt worked really well in our presentation was the variety of ways we used to share information, which hopefully was valuable to our classmates as they were able to engage with different learning styles and consider the information in different contexts. The information sent out in advance provided a foundation, the PowerPoint presentation organized and highlighted key pieces of information, the vignettes allowed for practical discussion and interaction with the material to ensure it was understood, and the Jeopardy game was a fun, engaging way to review. One area that could have used further work was to elaborate and expand on some of the individual points, perhaps by gathering real-life information and ideas from working psychologists on the practical side of implementing all of the ethical components of record keeping. We covered a good breadth of knowledge, but there would have been value in adding depth in certain areas.

Running head: RECORD KEEPING 6 Angela was responsible for presenting the Jeopardy portion of our presentation. With this responsibility came a lot of fun and review of the materials that Jo and Debby had covered throughout the first 45 minutes of the presentation. What she found to be very positive was the energy from the classmates as well as the contribution of everyone in the class. Angela felt that everyone was engaged and excited to work together to share the breadth of knowledge they had previously learned. An area of further improvement for this portion of the presentation was the technological aspect. Toward the end of Jeopardy, we kept losing the screen and getting kicked out of Elluminate, which was very frustrating. For future work, perhaps we would find a way to share the desktop and use Elluminate on the same computer, instead of going back and forth between two computers; this may help to eliminate the technical difficulties we were experiencing. We were fortunate to go back and watch the recorded version of our presentation and were relieved to hear that there was only about two minutes of confusion and then Jo-Anne went ahead and wrapped it up for us. Despite technical difficulties, overall Angela really enjoyed leading this part of our presentation. In closing, we would like to say that it was wonderful to have this opportunity to work together and to get to know our classmates at a closer level. We felt that we collaborated well and have consequently formed a BC bond as we have joined together geographically to complete this assignment. Thank you for this opportunity to create a future source of support that we will undoubtedly rely on over the next several years.

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Appendix: Annotated Bibliography American Psychological Association. (2007.) Record keeping guidelines. American Psychologist, 62 (9), 993-1004. Retrieved from http://www.apa.org/practice/guidelines/record-keeping.pdf This document provides guidelines for psychologists in developing record keeping systems. It discusses the background of the guidelines themselves and how they relate to the APA Ethics Code. The guidelines themselves discuss who is responsible for record keeping, content, confidentiality, disclosure, maintenance, security, retention, the use of electronic records, organizational settings, multiple clients, financial records and disposition of records. The guidelines are not designed to be a step-by step process, but rather provide a model for ethical record keeping in a variety of settings and contexts. BC Association of School Psychologists. (2010). Ethical conduct and professional practice. Vancouver: Author. Retrieved from http://www.bcasp.ca/cms_pdfs/Ethics%20March %202010.pdf This document describes the principles and standards that school psychologists in BC are expected to adhere, with to goal of ensuring that all students are protected and receiving a high standard of care. The ethical principles contained within are aspirational in nature, outlining what is considered the minimum expected behavior. This code contains four ethical principles: respect for the dignity of all persons, professional competence and responsible caring, integrity in professional relationships, and responsibility to schools, families, the profession and society. Each section contains a values statement and performance standards for each principle.

Running head: RECORD KEEPING 8 Canadian Psychological Association. (2000) Canadian code of ethics for psychologists (3rd ed). Ottawa: Author. Retrieved from http://www.cpa.ca/cpasite/userfiles/Documents/Canadian %20Code%20of%20Ethics%20for%20Psycho.pdf This document discusses the ethical principles and standards with which all psychologists who practice professional in Canada are expected to comply. The four principles are: respect for the dignity of persons, responsible caring, integrity in relationships, and responsibility to society. Each of the four principles are discussed and introduced with a values statement, which is then followed by specific ethical standards. Also including in this document is a description of the ten-step ethical decision-making process which is to be used when faced with an ethical dilemma that is easily resolved. Canadian Psychological Association. (2001). Practice guidelines for providers of psychological services. Ottawa: Canadian Psychological Association. Retrieved from http://www.cpa.ca/cpasite/userfiles/Documents/publications/Practice %20Guidelines2001%282%29.pdf This document is a supplement to the CPA Code of Ethics and provides practical guidelines for psychologists in the following areas: provision of service, organization of services, client relationships, record keeping, and training, qualifications and competence. These guidelines are designed to define common expectations, provide external authority for the standards, give direction to students within the profession, help guide legislation and give structure to a psychologists practice. College of Alberta Psychologist. (200). Code of conduct. Edmonton, AB: Author. Retrieved from http://library.athabascau.ca/caap603/codeofconduct.pdf

Running head: RECORD KEEPING 9 This document outlines the code of conduct for psychologists practicing in Alberta. It provides common definitions and information in the following areas: competence of the psychologist, impaired objectivity and dual relationships, relationship with supervisors, protecting confidentiality of clients, representation of service, fees and statements, assessment procedures, violations of law, and aiding illegal practice. College of Alberta Psychologists. (2005). Control and use of tests by psychologists. Edmonton, AB: Author. Retrieved from http://www.cap.ab.ca/pdfs/HPAPGFPControlandUseofTests.pdf This document was written by the College of Alberta Psychologists and serves as a professional guideline for psychologists and discusses the following issues involving use of tests: purpose, informed consent, protection of test takers, competency, test selection, alternate use, administration, interpretation of scores, confidentiality, reporting of results, use of results, test security, and currency. College of Alberta Psychologists. (2005). Standards of practice. Edmonton, AB: Author. Retrieved from http://www.cap.ab.ca/pdfs/HPAStandardsofPractice.pdf This document is intended for all persons who are employed by the Alberta Board of Examiners in Psychology. It provides information in the following categories: definitions, competence, providing supportable service, maintenance and retention of records, impaired objectivity and dual relationships, relationships with supervisee, protecting confidentiality of clients, representation of service, fees and statements, assessment procedures, violations of law, aiding illegal practice and general comments.

Running head: RECORD KEEPING 10 College of Psychologists of BC. (2009) Code of conduct. Vancouver, BC: Author. Retrieved from http://www.collegeofpsychologists.bc.ca/documents/Code%20of%20Conduct %202009%20full%20page%20version.pdf This document outlines the code of conduct for psychologists practicing in British Columbia. It provides common definitions, information on how to deal with ethical conflicts, and the consequences for not complying with the code. It then outlines the standards of practice in the following areas: competency, informed consent, relationships, confidentiality, professionalism, provision of services, self-representation, advertising and public statements, assessment procedures, fees, maintaining records, security and access to records, teaching, research, publishing and compliance with the law. Drogin, E.Y., Connell, M., Foote, W.E., Sturm, C.A. (2010). The American Psychological Associations revised Record Keeping Guidelines: Implications for the practitioner. Professional Psychology: Research and Practice, 41 (3), 236-243. doi:10.1037/a0019001 This document discusses the APA Record Keeping Guidelines. It goes through each of the guidelines, clarifying and discussing potential challenges that could arise in implementing the guidelines. It highlights areas where additional care is needed to ensure that the spirit of the guideline is understood and followed, rather than just the letter of the guideline, which may not translate to all contexts. It is designed to help the practitioner take the theoretical guidelines and develop a practical implementation strategy. National Association of School Psychologists. (2010) Principles for professional ethics. Bethesda, MD: Author. Retrieved from http://www.nasponline.org/standards/2010standards/1_%20Ethical%20Principles.pdf

Running head: RECORD KEEPING 11 This booklet documents National guidelines for the provision of school psychological services, principles for professional ethics, standards for the credentialing of school psychologists, and standards for training and field placement programs in school psychology. Nova Scotia Board of Examiners in Psychology. (2007) Standards of practice. Halifax, NS: Author. Retrieved from http://www.nsbep.org/downloads/Binder_Standards_Legislation_Guidelines.pdf This document is intended for all persons who are employed by the Nova Scotia Board of Examiners in Psychology. Employees are expected to be familiar with, and adhere to, all standards of professional conduct within this document as well as the Canadian Code of Ethics for Psychologists. This document outlines eight overlying principles and five standards or practice in which all Nova Scotia psychologists must respect and follow. The College of Psychologists of Ontario. (2005). Standards of professional conduct. Toronto, ON: Author. Retrieved from http://www.cpo.on.ca/assets/60F48DEF-3513-490F-B502FD46ADA6B78A.pdf This document is intended to be followed by all professional psychologists who are members employed by the College of Psychologists of Ontario. There are fourteen sections within this document; 1) acceptance of regulatory authority of the college, 2) compliance with statutes and regulations relevant to the provision of psychological services, 3) meeting client needs, 4) supervision, 5) competence, 6) representation of services, 7) consent to services, 8) privacy of personal information and health information, 9) records and record keeping, 10) fees and contract for service, 11) impairment, 12) professional objectivity, 13) harassment and sexual relationships, and 14) assessment and interventions. Employees are

Running head: RECORD KEEPING 12 expected to be familiar with, and adhere to, all standards of professional conduct within this document as well as the Canadian Code of Ethics for Psychologists. Truscott, D. & Crook, K. (2004). Ethics for the practice of psychology in Canada. Edmonton, AB: University of Alberta Press This book reviews professional ethics for psychologists written from the Canadian perspective, reflecting Canadian codes of ethics, laws and legislation. Each chapter contains an ethical case vignette that brings much discussion to the reader. This book is intended for students in professional psychology programs who intend to practice in Canada and for readers who want to explore ethics in greater depth.