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

Full text
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.