OAR 858-010-0060: Psychological Records

(1) Maintenance and retention of records. The psychologist or psychologist associate , or person granted a limited permit or temporary practice authorization, who is rendering professional services to an individual client or services billed to a third party payer, shall maintain professional records for a client for a minimum of seven years from the date of last service. The records shall include: (a) The name of the client and other identifying information; (b) The presenting problem(s) or purpose or diagnosis; (c) The fee arrangement; (d) The date and substance of each billed or service-count contact or service; (e) Any test results or other evaluative results obtained and any basic test data from which they were derived; (f) Notation and results of formal consults with other providers; (g) A copy of all test or other evaluative reports prepared as part of the professional relationship; (h) Any releases executed by the client; (i) Any signed informed consents. (2) Disposition in case of death or incapacity of the licensee. Psychologists and psychologist associates shall make necessary arrangements for maintenance of and access to client records to ensure confidentiality in case of death or incapacity of the licensee. (3) Oregon licensees shall name a qualified person to intercede for client welfare and to make necessary referrals, when appropriate, and shall keep the Board notified of the name of the qualified person. The Board shall not release the name of the qualified person except in the case of the death or incapacity of the licensee or if the licensee is inactive or has resigned and the former client is unable to locate the licensee. (4) A "qualified person" under this rule means an active or semi-active Oregon licensed psychologist. (5) Failure to comply with any provision of this rule, or misrepresentation of compliance, constitutes unprofessional conduct per ORS 675.070(2)(d) and (h) and is grounds for disciplinary action.