February 2024
Record Keeping
Question:
I am a regulated member of ACSLPA with a decade of experience running my own private practice. Although I intend to transition my client records to a digital format in the future, I currently work with paper files. Given the ACSLPA requirement to maintain client records for a length of time from the date of service according to Standards of Practice 4.3, how can I ensure the secure handling and storage of my existing paper records when I am closing my practice or if I unexpectedly become unable to maintain them?
Answer:
This is an excellent question that deserves careful consideration. Regardless of whether records are electronic or paper format, the secure handling, storage, and maintenance of client records are essential components of ethical and professional practice. ACSLPA’s Standards of Practice, 4.3 mandates regulated members to maintain clear, confidential, accurate, legible, timely, and complete records, in compliance with relevant legislation and regulatory requirements.
Considering the legal obligation to retain records for over a decade, it is important that practitioners proactively address potential challenges in this regard in order to mitigate the risk of privacy breaches and document abandonment.
Two options are available to ensure compliance with requirements in the event you are unable to manage your records in the long term:
Direct Return to Clients: Arrangements can be made for direct return of records to clients themselves if you are planning to close down your practice. Taking the time to inform your clients and to give them the opportunity to obtain their records can be a proactive approach to file management. This approach upholds client confidentiality and empowers them with control over their personal information.
Successor Agreement with Another Healthcare Professional: Engage in discussions with a trusted healthcare professional/colleague willing to assume responsibility for the records in the event you are no longer able to manage them, and document a plan that outlines how the files will be managed and what the transfer process will involve. If file transfer is required, clients should be informed, and should also be given the option of having their records transferred to an SLP or audiologist of their own choice, or to the client themselves.
For comprehensive guidance, please refer to the Clinical Documentation and Record Keeping Guideline-Record Management Upon Closure or Transfer of Practice, p.19 (June 2021).
If you have any questions or need further clarification, please contact ACSLPA’s SLP or Audiology Advisors through the Contact Us form.