Code of Colorado Regulations
700 - Department of Regulatory Agencies
721 - Division of Professions and Occupations - Board of Psychologists Examiners
3 CCR 721-1 - PSYCHOLOGIST EXAMINERS RULES AND REGULATIONS
Section 3 CCR 721-1.16 - RECORDS REQUIRED TO BE KEPT AND RECORD RETENTION (C.R.S. sections 12-245-204(4), 12-245-224(1)(u))

Universal Citation: 3 CO Code Regs 721-1 § 16

Current through Register Vol. 47, No. 5, March 10, 2024

A. General. Every psychologist engaged in the practice of psychology as defined in section 12-245-303, C.R.S., shall create and maintain records on each of his/her psychology clients. The psychologist shall retain a record on each psychology client for a period of seven years commencing on the date of termination of psychology services or on the date of last date of treatment with the client, whichever is later. Exception. When the client is a child, the record shall be retained for a period of seven years commencing either upon the last date of treatment or when the child reaches eighteen years of age, whichever is later.

B. Record. A record shall contain, as applicable to the mental health services rendered, at least the following information:

1. Name of the treating therapist;

2. Client's identifying data to include name, address, telephone number, gender, date of birth, and if applicable the name of the parent or guardian. If the client is an organization, the name of the organization, telephone number and name of the principal authorizing the mental health provider's services or treatment;

3. Reason for the psychology/psychotherapy services;

4. Mandatory disclosure statement(s);

5. Dates of service including, but not limited to the date of each contact with client, the date on which services began, and the date of last contact with client;

6. Types of service;

7. Fees;

8. Any release of information;

9. If any of the following have been written: assessment, plan for intervention, consultation, summary reports, and/or testing reports and supporting data. The records must be prepared in a manner that allows any subsequent provider to yield a comprehensive conclusion as to what occurred;

10. Name of any test administered, each date on which the test was administered, and the name(s) of the person(s) administering the test;

11. Information on each referral made to and each consultation with another therapist or other health care provider. This information shall include the date of referral or consultation, the name of the person to whom the client was referred, the name of the person with whom consultation was sought; the outcome (if known) of the referral, and the outcome (if known) of the consultation;

12. Records of counseling, interview notes, correspondence, audio or visual recordings, electronic data storage, and other documents considered professional information for use in counseling; and

13. A final closing statement (if services are over).

C. Record Storage. Every psychologist shall keep and store client records in a secure place and in a manner that both assures that only authorized persons have access to the records and protects the confidentiality of the records.

D. Transfer of Records. Whenever a psychologist deems it necessary to transfer her/his records to another psychologist or other health care provider, the psychologist making the transfer shall obtain the client's consent to transfer (when possible).

E. Disposition of records. If the psychologist is not available to handle her/his own records, the psychologist and/or his estate shall designate an appropriate person to handle the disposition of records. A plan for the disposition of records shall be in place for all psychologists for the following conditions:

1. Disability, illness or death of the psychologist;

2. Termination of the psychologist's practice.

F. Record Destruction. Every psychologist shall dispose of client records in a manner or by a process that destroys or obliterates all client identifying data. However, records cannot be destroyed until after seven years or as otherwise provided in these Rules or all other applicable statutes.

G. Record keeping in agency/institutional settings. A psychologist need not create and maintain separate client records if the psychologist practices in an agency or institutional setting and the psychologist:

1. Sees the client in the usual course of that practice;

2. Keeps client records as required by the agency or institution; and

3. The agency or institution maintains client records.

Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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