Sec. 10.36.07.05. Recordkeeping

A. The recordkeeping requirements of this regulation are in addition to the recordkeeping requirements in COMAR 10.36.05.

B. Supervisory Sessions.

(1) A supervisor and registered psychology associate shall maintain appropriate documentation of the nature and extent of the supervision provided or delegated, including the:

(a) Dates and duration of supervisory sessions;

(b) Client names or other identification for all cases;

(c) Outcome of each case reviewed;

(d) Signatures of both the supervisor and registered psychology associate; and

(e) Reason for any delegation of supervisory responsibility.

(2) A supervisor and registered psychology associate shall provide documentation of supervisory sessions upon request by the Board.

(3) Documentation of the supervisory sessions shall be maintained by the supervisor and registered psychology associate for at least 5 years.

C. Clinical Records.

(1) A registered psychology associate shall have the supervisor co-sign all clinical documents, including:

(a) Evaluations;

(b) Authorizations for release;

(c) Treatment plans; and

(d) Report.

(2) Except as otherwise required, after the initial entry of the supervisor’s name and license number in a client file or medical record, a registered psychology associate may omit repetitive references to the supervisor.

(3) Routine entries made by a registered psychology associate do not have to be cosigned by the supervisor, unless failure to do so would result in a misrepresentation of the services provided.

D. Documentation of site visits shall be maintained by the supervisor and the registered psychology associate for at least 5 years, and shall include:

(1) Date and time of visit;

(2) Site location; and

(3) Any issues or concerns relating to the registered psychology associate’s provision of services at the site.