How long should you keep clinical records?


The APA has updated and republished their “Record Keeping Guidelines” (2007 American Psychologist, 62:9, 993-1004). In this they discuss 13 separate guides (e.g., content of records, responsibility for records, confidentiality of records, retention of records, disposition of records, etc.).

How long should psychologists keep their records? This guideline suggests the full record is kept for a minimum of 7 years after the last service contact (for adult clients). Why should a psychologist destroy records? Some records might contain out-of-date assessment data that is either no longer valid or superseded by better tools. Some records might include information that was based on a very limited context and could be used against the client (e.g., 15 year old is seen for criminal activity but this information comes out at the age of 50…).

But consider the other side of destroying records. I once saw a client at a counseling center who was returning after 12 years for more counseling. This person had been in counseling for 3 years with a previous counselor who was no longer with the agency. Rules had allowed the disposal of his record. When I told him I could not review his prior record (he had asked that I do so) he was surprised and hurt that we did not keep his record. He felt that we had violated his trust in some way and that the good work that he had done was minimized. He felt the agency didn’t care about him and should have handled his history with more kindness.

So, how would you feel to go to your old therapist and find that your records no longer exist? 

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5 Comments

Filed under counseling and the law, Psychology

5 responses to “How long should you keep clinical records?

  1. Ron

    Several thoughts: Consider the occasional police TV show that shows warehouses of files and evidence. Also, I work in IT (“Information Technology”, once called “Data Processing”), and whether its information or data, it takes up space of some sort, and requires maintenance. When I consulted at certain companies, they had record retention policies that not only allowed data to be destroyed after several years, but *required* it. (I’m sure some legal sensibility was in this, since what you had to destroy cannot later be subpoenaed.) In any case, paper, CDs, disks, tapes: all take up space, and digital media becomes unreadable at some point.

    The other side, of course, is that a sense of identity and self is lost. “For *me*, that was significant history, not just notes on paper–and now it’s gone.”

    Makes me want to stop in every few years and top off my relationship with my counselor, just to keep things current.

  2. Good points about the data becoming unreadable. Oh, my records already are–because I can’t write to save my life.

  3. We destroyed a number of records a few years ago. Given that we have four different licenses represented in our group (psychology, social work, marriage & family, and professional counselors), it wasn’t easy figuring out what the minimum time for keeping patient records really was. Adolescent and child records need to be kept 7 years after the child reaches their majority.

    Our attorneys and liability insurance companies have since convinced us to NEVER destroy records. We are now in the process of scanning all patient record into pdf ‘s; the plan is to keep one copy on disks in the office and another copy on a removable hard drive. We are also looking into the possibility of keeping a third copy on some kind of online vault.

  4. Bob B.

    When I ended counseling after four years, due to my counselor’s retirement, I didn’t give any thought to what records he might have of our sessions. Four years later, as I jump back into counseling, those records, if they still exist, would be nice to have. I would be interested in seeing if my old counselor had the same perspectives on our time together as I do. But I’m kind of 50-50 on whether or not my new counselor should read those old files. There are parts of the old files that contain background information that would prove helpful to the new counselor in getting know me. My childhood background for instance, would be information that could save some counseling time. At the same time, I realize that I have changed a lot in four years of counseling and the interveening four years. If my old counselor were still practicing I might have gone back into counseling with him, but I’m not sure. In a way I’m glad he’s retired so that I am forced to get a fresh perspective on myself. I kind of like my new counselor not knowing what happened in the past. First, she only knows what I elect to tell her (a possible counseling discussion point), but mostly because I am different and want to be see as I am now. Yes, there are issues my old counselor and I never got to. The old records would help to identify them, but I know what they are, even if I deny some of them. For that we don’t need the old records, just fresh healing from the Holy Spirit thorugh the counseling process.

  5. nanah

    well inthink that records should not be thrown away because you never know if they wikll be needed in the future. if ancient people kept records in stones,caves shows that record keeping is important. in order to move on wirth your life you have to acknowledge the skeletons in your past and deal with them first.

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