What are core record-keeping expectations for PA psychologists?

• A. Discharge summaries and consent forms only.
• B. Discharge summaries and progress notes only.
• C. Document treatment plans, progress notes, risk assessments, test results, consent forms, and discharge summaries; maintain records securely.
• D. No documentation required.

Answer: (C)

Comprehensive and securely stored documentation is essential. For PA psychologists, the expected records include treatment plans, progress notes, risk assessments, test results, consent forms, and discharge summaries, all accurately dated and signed as appropriate. Each element serves a purpose: treatment plans outline goals, treatment modalities, and expected timelines; progress notes show client responses, symptom changes, and treatment decisions over time; risk assessments identify safety concerns, risk level, and mitigation steps; test results and interpretations provide objective data to monitor progress; consent forms document informed consent, client rights, and scope of treatment; discharge summaries wrap up care, summarize outcomes, and provide recommendations for future care. Keeping these records securely protects confidentiality and meets legal and ethical standards, including privacy laws and professional regulations. Incomplete documentation fails to demonstrate continuity of care or compliance, while keeping only some items (like discharge summaries or consent forms alone) would omit critical information for ongoing treatment and accountability.