|(a) General Requirements.
(1) All licensees shall create and maintain accurate,
current, and pertinent records of all psychological services rendered
by or under the supervision of the licensee.
(2) All records shall be sufficient to permit planning
for continuity in the event that another care provider takes over
delivery of services to a patient or client for any reason, including
the death, disability or retirement of the licensee and to permit
adequate regulatory and administrative review of the psychological
(3) All licensees shall identify impressions and tentative
conclusions as such in patient or client records.
(4) All records and record entries shall be created
in as timely a manner as possible after the delivery of the specific
services being recorded.
(5) Records, test data and test protocols shall be
maintained and stored in a way that permits review and duplication.
(6) Licensees working in public school settings shall
comply with all federal and state laws and regulations relative to
the content, maintenance, control, access, retention and destruction
of psychological and educational records, test data and test protocols.
(7) Licensees are prohibited from falsifying, altering,
fabricating, or back-dating patient records and reports.
(b) Maintenance and Control of Records and Test Data.
(1) Licensees shall maintain records and test data
in a manner that protects the confidentiality of all services delivered
by the licensee.
(2) Licensees are responsible for the maintenance,
confidentiality and contents of, and access to, all records and test
(3) Licensees shall make all reasonable efforts to
protect against the misuse of any record or test data.
(4) Licensees shall maintain control over records and
test data to the extent necessary to ensure compliance with all applicable
Board rules and all state and federal laws.
(5) In situations where it becomes impossible for a
licensee to maintain control over records and test data as required
by applicable Board rule and state and federal law, the licensee shall
make all necessary arrangements for transfer of the licensee's records
to another licensee who will ensure compliance with all applicable
Board rules and state and federal laws concerning records.
(6) Records and test data of psychological services
rendered by a licensee as an employee of an agency or organization
remain the property of the employing agency upon termination of the
employment of the individual unless legal ownership of such records
is controlled by applicable state or federal law or legal agreement.
(c) Access to Records and Test Data.
(1) Records shall be entered, organized and maintained
in a manner that facilitates their use by all authorized persons.
(2) Records may be maintained in any media that ensure
confidentiality and durability.
(3) A licensee shall release information about a patient
or client only upon written authorization by the patient, client or
appropriate legal guardian pursuant to a proper court order or as
required by applicable state or federal law.
(4) Test data are not part of a patient's or client's
record. Test data are not subject to subpoena. Test data shall be
made available only:
(A) to another qualified mental health professional
and only upon receipt of written release from the patient or client,
(B) pursuant to a court order.
(5) Licensees cooperate in the continuity of care of
patients and clients by providing appropriate information to succeeding
qualified service providers as permitted by applicable Board rule
and state and federal law.
(6) Licensees who are temporarily or permanently unable
to practice psychology shall implement a system that enables their
records to be accessed in compliance with applicable Board rules and
state and federal law.
(7) Access to records may not be withheld due to an
outstanding balance owed by a client for psychological services provided
prior to the patient's request for records. However, licensees may
impose a reasonable fee for review and/or reproduction of records
and are not required to permit examination until such fee is paid,
unless there is a medical emergency or the records are to be used
in support of an application for disability benefits.
(8) No later than 15 days after receiving a written
request from a patient to examine or copy all or part of the patient's
mental health records, a psychologist shall:
(A) make the information available for examination
during regular business hours and provide a copy to the patient, if
(B) inform the patient in writing that the information
does not exist or cannot be found; or
(C) when withholding information, provide the patient
with a signed and dated statement reflecting the licensee's determination,
based upon the exercise of professional judgment, that the access
requested is reasonably likely to endanger the life or physical safety
of the patient or another person. The written statement must specify
the portion of the record being withheld, the reason for denial and
the duration of the denial.
(d) Retention of Records and Test Data.
(1) Licensees shall comply with all applicable laws,
rules and regulations concerning record retention.
(2) In the absence of applicable state and federal
laws, rules and regulations, records and test data shall be maintained
for a minimum of seven years after termination of services with the
client or subject of evaluation, or three years after a client or
subject of evaluation reaches the age of majority, whichever is greater.
(3) All records shall be maintained in a manner which
permits timely retrieval and production.
(e) Outdated Records.
(1) Licensees take reasonable steps when disclosing
records to note information that is outdated.
(2) Disposal of records shall be done in an appropriate
manner that ensures confidentiality of the records in compliance with
applicable Board rules and state and federal laws.
|Source Note: The provisions of this §465.22 adopted to be effective June 3, 1999, 24 TexReg 4017; amended to be effective March 13, 2000, 25 TexReg 2061; amended to be effective March 13, 2001, 26 TexReg 2023; amended to be effective February 21, 2002, 27 TexReg 1170; amended to be effective May 30, 2007, 32 TexReg 2864; amended to be effective June 5, 2008, 33 TexReg 4325; amended to be effective March 12, 2013, 38 TexReg 1687; amended to be effective September 26, 2013, 38 TexReg 6208