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October 2024

Electronic Retention of Assessment Protocol Forms

Question:

I’m an SLP for a not-for-profit organization in Alberta and my employer is transitioning to electronic record keeping. I have some questions about what this means for retaining paper copies of assessment protocol forms. My employer is asking me to scan the paper copies of the assessment protocols I fill out by hand during assessments with clients and to shred the paper copies once this is complete. I have some questions about this:

  1. Is it permissible to retain assessment protocol forms only in electronic format? Do paper copies also need to be retained?
  2. Does the entire assessment protocol form need to be retained? Or is it permissible to scan and save only the protocol cover page which shows the client’s scores?

Answer:

Employers and clinicians across the province are increasingly transitioning to electronic files for a variety of reasons, including convenience, ease of record retrieval, greater accessibility, cost and environmental considerations, etc. While there are many advantages to electronic record keeping, there are considerations specific to electronic records that regulated members must be mindful of. Please refer to ACSLPA’s Documentation and Information Management Standard of Practice and Guideline on Clinical Documentation and Record Keeping for information specific to the expectations for electronic records.

As per ACSLPA’s Clinical Documentation and Record Keeping Guideline, records, including assessment protocols, may be retained in either paper OR electronic format. From the College perspective, it is therefore permissible to retain assessment protocol forms only in electronic formats, with the following considerations:

  • ACSLPA’s standards of practice on record retention (see Standard of Practice Documentation and Information Management) and privacy and confidentiality (see Standard of Practice Privacy/Confidentiality) apply to paper as well as electronic records. Regulated members should review these standards, as well as all other applicable standards, to ensure that their electronic record keeping practices follow the requirements of the College.
  • Paper records that are transferred to electronic formats (e.g., scanning and uploading an assessment protocol) must be reviewed to ensure that they are legible and that all relevant information has been saved prior to destroying hard/paper copy versions.
  • It is the regulated member’s responsibility to ensure compliance with any requirements, recommendations, or guidelines for electronic retention of assessment protocols put forth by test publishers. For example, some publishers may prohibit the conversion of paper copies of their assessment protocols into electronic formats entirely, while others may require that test items (questions) are not saved electronically, or that protocol forms are retained separately to a client’s general file (for copyright and intellectual property protection reasons). Regulated members and their program administrators (where applicable) should take steps to familiarize themselves with any publisher requirements and weigh the practicality and feasibility of these when making decisions about electronic retention of assessment protocol forms for their practice setting.

ACSLPA’s guidance is that the complete assessment protocol form must be retained (i.e., the protocol cover page with the client’s scores as well as all subsequent pages showing the client’s performance on individual test items). This allows clinicians to meet the requirements of Standard 4.3 of Documentation and Information Management, by ensuring that adequate information is documented to support a regulated member’s clinical reasoning and judgement (e.g., of their scoring, interpretation, diagnoses, or recommendations based on assessment results), and that sufficient detail is retained that would allow a client to be managed by another clinician. For example, on re-testing, it would be important to be able to identify in which areas clients demonstrated change, and not simply a change in their overall score(s) on a standardized assessment . In addition, in the event of a complaint, depending on its nature, it may be necessary to review assessment protocols and scoring as part of an investigation.

There may be situations where employer policy does not allow for the storage of raw data on assessment protocols on the client’s main health record or cumulative file. In  these situations, as per ACSLPA Standard 4.3 Documentation and Information Management, regulated members have an obligation to be aware and inform employers of their professional obligations regarding documentation and record keeping. While such circumstances may pose challenges to regulated members, it remains their responsibility to ensure minimum practice standards are met. Regulated members are encouraged to work with their employers and program administrators to ensure that all client information (including the information in assessment protocols) is retained according to College standards. Regulated members can contact ACSLPA for further discussion and support should a situation like this arise in their professional practice.

If you have any questions or need further clarification, please contact ACSLPA’s SLP or Audiology Advisors through the Contact Us form.