Record Retention and Client Notes Policy – Psychology Practice

Description

Maintaining accurate, secure, and compliant client records is a legal, ethical, and professional obligation for psychologists. A Digital Record Retention & Notekeeping Policy ensures:

1. Compliance with Legal & Regulatory Requirements

• AHPRA and professional bodies (e.g., APS) mandate proper record-keeping.

• Failure to retain or destroy records correctly can lead to disciplinary action, fines, or legal consequences.

2. Protection Against Legal & Ethical Risks

• Proper documentation defends against complaints, audits, or litigation (e.g., subpoenas, client disputes).

• A clear policy prevents accidental breaches of privacy laws (e.g., Privacy Act 1988).

3. Efficient & Secure Record Management

• Ensures consistent, organized storage of client notes, assessments, and reports.

• Reduces clutter and unnecessary data retention, saving time and digital storage costs.

4. Client Trust & Professional Accountability

• Clients have a right to access their records—this policy ensures transparency and minimises indefinite exposure.

• Ethical practice demands accurate, up-to-date, and confidential record-keeping.

5. Streamlined Practice Operations

• Clear guidelines for staff on what to keep, for how long, and when to securely destroy records.

• Avoids confusion, duplication, or accidental deletion of critical files.

6. Preparedness for Audits or Investigations

• If a complaint, subpoena, or audit arises, records must be preserved—this policy ensures compliance.

• Prevents spoliation of evidence (destruction of relevant records), which can have serious legal consequences.

Key Features of This Policy:

• Standardized retention periods (e.g., 7 years for client notes).
• Secure digital storage (avoiding paper-based risks like loss or damage).
• Clear rules on email/document retention (what to keep vs. delete).
• Procedures for suspension of record deletion processes (e.g., if a complaint or subpoena is received).
• Alignment with APS guidelines (single-record system for consistency).

Our templates are drafted in plain English. We don’t use complex legalese or longwinded definitions. Our templates are designed to be relied on by busy practitioners to keep things fair, compliant and simple.

Jurisdiction: Australia (all States and Territories) (Not suitable for use outside Australia).

Who Can Use It?

This product is suitable for any psychology practitioner retaining clients for direct one-on-one therapeutic treatment.

What Is Included?

This Product is a digital download. Purchase provides access to:

• Single editable word document (.docx format) with a range of optional clauses.

Purchase provides a single license for use by the purchasing party. The product may be implemented on a website as the terms of use to be relied on by online booking software.

How Do I Use it?

How Long Will I Have Access For?

GST