C-26, r. 221 - Regulation respecting the keeping of records and consulting-rooms by psychologists

Updated to 1 September 2012

This document has official status.

chapter C-26, r. 221

Regulation respecting the keeping of records and consulting-rooms by psychologists

Professional Code

(chapter C-26, s. 91).

DIVISION I KEEPING OF RECORDS

1. Subject to sections 12 and 13, a psychologist entered on the roll of the Ordre professionnel des psychologues du Québec shall keep a record for each of his clients at the place where he practises his profession.

A psychologist shall ensure that each record is filed and kept up to date.

O.C. 448-92, s. 1.

2. A psychologist may use data processing or any other method in constituting and keeping his records, provided that the confidentiality of the information contained therein is ensured.

O.C. 448-92, s. 2.

3. A psychologist shall enter the following information in each record:

(1)  the date of opening the record;

(2)  where the client is a natural person, his name at birth, sex, date of birth, address and telephone number;

(3)  where the client is a partnership or legal person, its name, business address and telephone number, together with the full name, address, telephone number and title of the position of an authorized representative;

(4)  a brief description of the reasons for the consultation;

(5)  a brief description of the professional services provided and their dates;

(6)  the conclusions deriving from the psychological assessment or a description of the treatment plan and recommendations;

(7)  notes on the client’s progress after services have been provided;

(8)  any document pertaining to the sending of information to third parties, in particular any document signed by the client and authorizing the sending of such information;

(9)  a copy of any service contract or the description of any special agreement concerning the nature and procedures of treatment;

(10)  the signature of the psychologist who has entered the information mentioned in paragraphs 1 to 9 in the record.

O.C. 448-92, s. 3.

4. Notwithstanding sections 1 and 3, a psychologist may, for a group consultation, keep a single record for any treatment including the information mentioned in paragraph 2 of section 3, a description and evaluation of the treatment and, where applicable, the information mentioned in paragraph 9 of section 3.

O.C. 448-92, s. 4.

5. Without restricting the scope of section 3, a psychologist shall avoid adding to a file any unprocessed data or any unverified information that could harm the client.

O.C. 448-92, s. 5.

6. A psychologist shall keep the record of each client up to date until he ceases to provide professional services to the client.

O.C. 448-92, s. 6.

7. A psychologist shall keep his records in a cabinet that is not readily accessible to the public and that can be locked with a key or otherwise.

O.C. 448-92, s. 7.

8. A psychologist shall keep each record for at least 5 years from the date of the last professional services provided.

O.C. 448-92, s. 8.

9. Subject to section 8, a psychologist may destroy a record, provided that he does so in a manner that ensures the confidentiality of the information contained in the record.

O.C. 448-92, s. 9.

10. Where a client requests that a copy of his record or some information in his record be sent to a third party, the psychologist may provide the information not less than 15 days following the date of the authorization signed by the client to that effect. The client may within that period revoke his authorization. Nevertheless, the client may, in an emergency, renounce the 15-day period.

Where a client is sent a copy of a document in his record, or where a client requests that such a copy or information in the records be sent to a third party, the psychologist shall add to the record a note to that effect that is signed by the client and dated.

O.C. 448-92, s. 10.

11. A psychologist adding all or some of the information mentioned in section 3 to a client’s record shall ensure that the provisions of section 10 are complied with where a copy of a document in the record and pertaining to his services is sent to the client in question or to a third party.

O.C. 448-92, s. 11.

12. Where a psychologist practises in an institution within the meaning of the Act respecting health services and social services (chapter S-4.2) or the Act respecting health services and social services for Cree Native persons (chapter S-5), the record of a recipient within the meaning of those Acts and their regulations is considered, for the purposes of this Regulation, to be the record kept by the psychologist if he is able to enter or have entered in the record, as a report or otherwise, the information mentioned in section 3, provided that the confidentiality of the record is ensured. Sections 8 to 10 do not apply to that psychologist.

A psychologist shall sign or initial any entry he adds to the record.

O.C. 448-92, s. 12.

13. Where a psychologist is a member of or employed by a partnership or where he is employed by a natural or legal person, he may enter in the records of the partnership or employer all or some of the information mentioned in section 3 concerning clients to whom he provided services, provided that the confidentiality of the records is ensured. If the information is not entered in the records of the partnership or employer, the psychologist shall keep a record for each of his clients.

A psychologist shall sign or initial any entry or report he adds to the records of the partnership or employer.

O.C. 448-92, s. 13.

DIVISION II KEEPING OF CONSULTING-ROOMS

14. A psychologist’s consulting-room must be so designed that the identity of the persons therein cannot be established or their conversations heard from outside the room.

A consulting-room must not include the waiting room or any room in which a psychologist or his employees work.

O.C. 448-92, s. 14.

15. A psychologist shall have a waiting room for his clients near his consulting-room.

O.C. 448-92, s. 15.

16. A psychologist practising in an institution shall hold his consultations in a consulting-room complying with this Regulation.

O.C. 448-92, s. 16.

17. A psychologist shall post his permit in public view.

O.C. 448-92, s. 17.

18. A psychologist shall post in his waiting room a copy of the Code of ethics of psychologists (chapter C-26, r. 212), a copy of this Regulation and, where a psychologist charges his clients fees, a copy of the Regulation respecting the procedure for conciliation and arbitration of the accounts of psychologists (chapter C-26, r. 220). He shall also write the address of the Order on the copy of each of those regulations.

O.C. 448-92, s. 18.

19. A psychologist may, in addition to decorative or utilitarian objects, display only diplomas related to the practice of his profession in his consulting-room and any other room used in that practice.

O.C. 448-92, s. 19.

20. A psychologist who is absent from his consulting-room for more than 5 consecutive working days shall take the necessary measures to inform clients trying to contact him of the length of his absence and of the procedure to follow in an emergency.

O.C. 448-92, s. 20.

21. Where the work environment of a psychologist not practising for his own account or in partnership hinders compliance with a provision of this Regulation, the psychologist shall, after informing his employer thereof in writing, notify the Order of the situation.

O.C. 448-92, s. 21.

22. (Omitted).

O.C. 448-92, s. 22.

REFERENCES

O.C. 448-92, 1992 G.O. 2, 1886

S.Q. 1992, c. 21, s. 375