Record Keeping Policy
1. Purpose
This policy ensures consistent, ethical, and legally compliant management of client records in accordance with the Psychology Board of Australia’s Record-Keeping Guidelines (2023) and the Health Records (Privacy and Access) Act 1997 (ACT).
2. Record Creation
A record is created for every client upon intake, including:
– Personal and contact information
– Referral details and consent forms
– Session notes and treatment plans
– Correspondence and reports
3. Format and Storage
Records may be maintained in paper or electronic format. Electronic records are stored on secure, password-protected systems. Paper records are stored in locked cabinets.
4. Content of Session Notes
Session notes must include the date, presenting issues, interventions, risk assessments, and outcomes. Records must be accurate, factual, and objective.
5. Retention Periods
Client records are kept for a minimum of seven (7) years following the last contact. For clients under 18 years of age, records are retained until the client reaches 25 years of age.
6. Access & Correction
Clients may request access to or correction of their records by written request. Requests are managed according to privacy legislation.
7. Destruction of Records
When the retention period has expired, records are securely destroyed using methods such as shredding (for paper) or secure digital deletion.
8. Professional Executor
In the event of incapacity or death of the psychologist, a nominated Professional Executor may access client records solely for continuity of care, notification, or lawful closure of the practice.
9. Confidentiality
All personnel accessing client information must comply with confidentiality obligations under the APS Code of Ethics and Privacy legislation.
Effective Date: 25 March 2026