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Record Keeping in Ohio
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According to Ohio law, what information must be kept in the record?

Ohio Administrative Code


4732-17-01 General rules of professional conduct pursuant to section 4732.17 of the Revised Code.


(7) Maintenance and retention of records.

(a) A license holder rendering professional individual services to a client, or services billed to a third-party payer, shall maintain a professional record that includes:

(i) The presenting problem(s),

(ii) The date(s) and purpose, if not self-evident, of each service contact,

(iii) The fee arrangement,

(iv) Any test or other evaluative results obtained,

(v) Test data,

(vi) A copy of any test or other evaluative reports prepared as part of the professional relationship,

(vii) Notation of providing verbal communication of assessment results in the absence of a written report,

(viii) Notation and results of formal contacts with other providers,

(ix) Authorizations, if any, by the client for release of records or information,.

(x) Written documentation indicating that the client or evaluee has provided informed consent for treatment or evaluation,

(xi) Justification and rationale for not releasing records to a client in response to a valid request, including the reason for making a determination for clearly stated treatment reasons that disclosure of the requested records is likely to have an adverse effect on the client, and shall comply with section (B) of division 3701.74 of the Revised Code.

(xii) Knowledge of all multiple relationships present, with reasoning as to why it is in the best interest of the client and/or not harmful to continue the professional relationship, and

According to Ohio law, how long should records be kept?

OAC 4732-17-01 (B) Negligence:

(7) Maintenance and retention of records.

(b) To meet the requirements of these rules, but not necessarily for other legal purposes, the license holder shall ensure that all contents in the professional record are maintained for a period of not less than seven years after the last date of service rendered, or not less than the length of time required by other regulations if that is longer. A license holder shall retain records documenting services rendered to minors for not less than two years after the minor has reached the age of majority or for seven years after the last date of service, whichever is longer.

What are the HIPAA requirements for retaining HIPAA documentation?

According to the Health Insurance Portability and Accountability Act (HIPAA), all HIPAA documents should be retained for six years. HIPAA documents include all the forms and releases that are specifically related to HIPAA requirements. Depending on how you keep your records, HIPAA documents would not necessarily include your treatment notes.

How does record keeping differ for work with children?

Because children have rights to legal remedies for childhood abuse after they reach the age of majority, many psychologists who work with children choose to keep their records longer than required by Ohio law. For child non-sexual abuse cases, keep records until the child is 24 years old. For child sexual abuse cases, keep records until the child is 38 years old.


 

Additional Resources

American Psychological Association Record Keeping Guidelines
Reference guide containing additional record retention information for Ohio
Release of Records
Record Keeping Guidelines for the Retiring/Retired Psychologists (coming soon)

 


 

Disclaimer: Psychologists should be familiar with legal and ethical requirements for record keeping in their specific professional contexts and jurisdictions. These guidelines are not intended to describe these requirements fully or to provide legal advice.