Ultimately, you have to assume that someday, sometime, somewhere, somebody is going to go through your files in detail. It might be a supervisor who oversees your work, an attorney who requests the file for a client, another psychologist who takes over your work, or an accrediting person who is checking files for everyone at your agency. Keeping the file correctly is very important.

testing Case Files

A testing case file should include:

  • dates of contact and work/services offered and completed
  • documentation of consent for testing, release, and audio/video taping
  • fees and payments
  • testing reports
  • records provided
  • notes from collateral contacts
  • names, addresses, and dates for anyone the report was released to

A testing case file should NOT include:

  • your scribbled notes about the case
  • things you copied out of a book, article, or other interpretive source
  • messy copies of handwritten data (e.g., Rorschach answers, TAT responses...)

Other Recommendations

Other recommendations include:

  • APA says to keep detailed records for at least three years after ending the relationship with the client, with summaries of the complete records for another 12 years
  • APA also recommends purging from records outdated information as needed
  • document supervision times for the case and client as well

Client Rights

Client rights include:

  • the right to review the records, meaning the entire file. Thus, assume anything in the folder can be seen by the client or their attorney. Make sure everything is very professional - scribble five things you need from the store on a paper pad, set it down, then pick it up later and take notes from an interview on it, and it will look like you were thinking about your shopping list while conducting the interview
  • the right to know how their records are going to be stored, who has access to them, and why they might be accessed
  • the right to submit a restriction on disclosure (for example, revoking consent to release to the referring agency if the caseworker changes for the case), restrictions regarding contact (for example, you may only contact the client on their cell phone and not their work number), and amendments to the record