Your follow-up questions and replies from NSRP are (in bold) below.
Where is the original completed test kept (is it part of the patient’s medical record in a clinic) or is it stored separate from the patient’s medical record?In order to meet standards, psychologists have stored the raw data and protocols separately from the medical record.
If the test is not kept with the medical record, does a summary need to be written in the patient’s medical record detailing the results of the test?YesnDoes the completed test have to be locked up?The standards expect that access be restricted to those competent to interpret results.
For how long is the original completed test material kept?Unless otherwise required by law a registrant shall retain both individual and corporate client records for at least ten years following the last client contact. If an individual client was less than eighteen years of age at the time of last contact, the individual client record shall be retained for ten years following the date of the client’s eighteenth birthday.
For reference to the Standards, Guidelines and Legislation psychologists are expected to follow, you may consult the following URL:
https://www.ns-rp.ca/downloads/Binder_Standards_Legislation_Guidelines.pdf
The NSRP has responded to registrants reaching out about raw data and test protocols, as well as having been in contact with Government contacts and others as noted below.
Here is the response that we have provided.
The Personal Health Information Act (PHIA) provides that the NS Health Authority is the Custodian of records. As such, we recognize they would be responsible for ultimately making decisions on such matters, but could delegate specific functions to employees who would act as “Agents”. If the Custodian is amenable to putting in place some type of mechanism to lock down the portion containing the raw data and testing material protocols that would be ideal; however, it may not be what they ultimately agree to, so we must consider the following clause from the Standards for Providers of Psychological Service in such a matter, along with the realities of PHIA:”Since the Nova Scotia Regulator of Psychology has the right to regulate psychology only, these Standards are to be understood to refer to psychological services and training (as opposed to services and training in other professions), even where the adjective “psychological” is not explicitly used, and psychological service units are not intended to interfere with the larger organizational structure in which they are embedded.”The NSRP recognizes that the reality of the NSHA being the custodian places psychologists in a challenging position with respect to standards where they conflict with the direction of the custodian. We have contacted our representatives with the NS Department of Health and Wellness to share these challenges and concerns. In response, we were advised that as an initial response, the first stage of this conversation should take place between the registrants and NSHA in the role of employer. This is recommended to ensure that the concerns have been fully and officially communicated to NSHA. You may find it helpful to share the above information with NSHA.
We are also consulting with other regulatory NSRPs across Canada to see if there are any other practices being followed that we could consider adapting. I have heard back from the Registrar in Alberta, and he indicated that Alberta Health Services has made specific arrangements to have test data access highly restricted and separate from the main clinical file. It would be nice if Nova Scotia Health would consider doing the same.
Registrar
