02-415-9 Me. Code R. § 2

Current through 2024-51, December 18, 2024

Section 415-9-2 - Maintenance and Retention of Records

1. Maintenance

Licensees shall maintain a record for each client that includes:

A.The name of the client and other identifying information;

B.The presenting problem(s) or purpose or diagnosis;

C.The fee arrangement;

D.The date and substance of each billed or service-count contractor service;

E.Any test results or other evaluative results obtained and any basic test data from which they were derived;

F.Notation and results of formal consults with other providers;

G.A copy of all test or other evaluative reports prepared as part of the professional relationship; and

H.Any releases executed by the client.

2. Retention

Licensees shall retain full client records for at least 7 years following the date of last contact with the client, and shall retain a treatment summary for at least 15 years following the date of last contact. In addition, in the case of clients who were minors on the date of last contact, full records must be retained until at least 3 years after the client has attained the age of majority, and the treatment summary must be retained until at least 15 years after the client has attained the age of majority.

02-415 C.M.R. ch. 9, § 2