Md. Code Regs. 10.36.05.08

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.36.05.08 - Confidentiality and Client Records

A. A psychologist or psychology associate shall:

(1) Maintain confidentiality regarding information obtained from a client in the course of the psychologist's or psychology associate's work;

(2) Discuss the requirements and limitations of confidentiality at the beginning of the professional relationship or at the intake interview;

(3) Safeguard information obtained in clinical or consulting relationships or evaluative data concerning children, students, employees, and others obtained in the course of practice, teaching, research, or other professional services;

(4) Release mental health records or other confidential information only as permitted or required by law;

(5) Obtain written permission for the electronic recording of interviews;

(6) Avoid undue invasion of privacy by ensuring that written and oral reports contain only data relevant to the purpose of the evaluation;

(7) Treat any assessment result or interpretation regarding an individual as confidential information; and

(8) Obtain informed written consent before presenting in writing, lecture, or other public forums identifying information obtained during the course of professional work, and disguise this information when case reports or other confidential information are used as a basis for teaching or research.

B. Legal and Ethical Limits. A psychologist or psychology associate shall inform:

(1) Clients of the legal and ethical limits of confidentiality;

(2) Clients below the age of minority, or who have legal guardians, of the limits the law imposes on the right of confidentiality with respect to communications with the psychologist or psychology associate, to the extent that the client can understand, at the beginning of the professional relationship;

(3) Research participants of any limits to confidentiality as part of the informed consent; and

(4) Clients of the duty imposed by law to inform authorities of abuse and neglect of children and vulnerable adults.

C. Record Keeping. A psychologist or psychology associate shall:

(1) Keep records of a patient's condition and assessment results;

(2) Maintain clinical records of informed consent, presenting problems, diagnosis, fee arrangements, dates and substance of each billed service, original test data with results and other evaluative material, and the results of any formal consultations with other professionals;

(3) Make provisions for maintaining confidentiality in the storage and disposal of written and electronic records;

(4) Ensure that professional records are maintained for a period consistent with State and federal laws;

(5) Limit access to client records and ensure that a person working under the psychologist's or psychology associate's authority including, but not limited to office personnel, comply with the requirements for confidentiality of client material; and

(6) Provide evaluations or treatment reports within a reasonable time consistent with State and federal laws on proper and lawful requests by a client, insurance carrier, court, institution, or other authorized health provider.

Md. Code Regs. 10.36.05.08

Regulations .08 adopted effective November 10, 2003 (30:22 Md. R. 1582)
Regulation .08 amended effective 42:10 Md. R. 684, eff.5/25/2015