(1) A psychologist who renders professional services to a client or clients, or renders services billed to a third party payor, shall document services except as provided in (g) of this subsection. The documentation must include:
(a) The presenting problem(s), purpose, or diagnosis;
(b) The fee arrangement;
(c) The date and service provided;
(d) A copy of all tests and evaluative reports prepared;
(e) Notation and results of formal consults including information obtained from other persons or agencies through a release of information;
(f) Progress notes reflecting ongoing treatment and current status; and
(g) If a client requests that no treatment records be kept and the psychologist agrees to the request, the client's request must be in writing and retained with the following information:
(i) Identity of the recipient of the services;
(ii) Service dates and fees;
(iii) Description of services;
(iv) The psychologist shall not agree to the request if maintaining records is required by other state or federal law.
(2) All records must be retained for at least eight years following the last professional contact with the client(s). In the case of minors under the age of eighteen, the records must be retained until the client reaches the age of twenty-two or for eight years, whichever is longer.
All records must be securely maintained with appropriate limited access in accordance with any other applicable state or federal laws.
(3) The psychologist rendering services must have a written policy to ensure the maintenance and confidentiality of the client records in the event of retirement, discontinuation of practice or employment, discontinuation of practice in the state of Washington, or inability to maintain practice or employment (e.g., illness or death of the psychologist).
This written policy must be made available to the board, upon written request, within sixty days. The written policy shall:
(a) Designate a qualified person(s) or, if appropriate, hospital, clinic or other health care facility, to make necessary clinically relevant referrals if the psychologist is unable to do so;
(b) Detail a plan for fulfilling record requests described under this subsection; and
(c) Require the subsequent record holder to maintain records in accordance with any other applicable state or federal laws or rules.
(4) In the case of psychological or neuropsychological evaluations, tests or assessments, the psychologist may exercise clinical judgment in determining whether or not to retain specific records beyond the minimum retention period specified in subsection (2) of this section.
(5) After the minimum records retention period is met for a client record, the psychologist may elect to dispose of the record. If the record is disposed of, it shall be done in a secure and confidential manner. Proper disposal means paper is shredded; electronic media is deleted, erased, or reformatted; and other readable forms of media is defaced or rendered unusable or unreadable.
[Statutory Authority: RCW 18.83.050, 18.130.050. 05-19-048, § 246-924-354, filed 9/15/05, effective 10/16/05. Statutory Authority: RCW 18.83.050(5) and chapter 18.83 RCW. 93-07-036 (Order 337B), § 246-924-354, filed 3/10/93, effective 4/10/93.]