Florida Administrative Code
64 - DEPARTMENT OF HEALTH
64B19 - Board of Psychology
Chapter 64B19-19 - PSYCHOLOGICAL RECORDS AND CONFIDENTIALITY
Section 64B19-19.0025 - Standards for Records

(1) Records for chronicling and documenting psychologists' services must include the following: basic identification data such as name, address, telephone number, age and sex; presenting symptoms or requests for services; dates of service and types of services provided. Additionally, as applicable, these records must include: test data (previous and current); history including relevant medical data and medication, especially current; what transpired during the service sessions; significant actions by the psychologist, service user, and service payer; psychologist's indications suggesting possible sensitive matters like threats; progress notes; copies of correspondence related to assessment or services provided; and notes concerning relevant psychologist's conversation with persons significant to the service user.

(2) Written informed consent must be obtained concerning all aspects of services including assessment and therapy.

(3) A provisionally licensed psychologist must include on the informed consent form the fact that the provisional licensee is working under the supervision of a licensed psychologist as required by section 490.0051, F.S. The informed consent form must identify the supervising psychologist.

(4) Records shall also contain data relating to financial transactions between the psychologist and service user, including fees assessed and collected.

(5) Entries in the records must be made within ten (10) days following each consultation or rendition of service. Entries that are made after the date of service should indicate the date the entries are made, as well as the date of service.