Publications
Electronic Health Record Templates
APA Divs. 31 (State, Provincial and Territorial Affairs) and 42 (Psychologists in Independent Practice) have summarized the record-keeping laws of each state and compiled state-specific electronic health record (EHR) templates that are required because of state-specific laws. Before using the free EHR templates for your state, please review the digest of your state's record-keeping laws. The digests and the EHR templates are a benefit of APA membership and should assist in the implementation of the Affordable Care Act, which will require EHR use among integrated health care clinicians.
The state-specific EHR templates comply with the laws of each jurisdiction. State leaders have reviewed their digests and the templates through the volunteer efforts of their member experts on ethics/law as of 2014.
These templates should be used as a starting point for these types of electronic records. As laws can change, please contact your state association to verify whether there have been changes in your jurisdiction’s record-keeping duties. If any of the laws do change, please contact Andy Benjamin, JD, PhD, ABPP, so changes can be made to the state’s digest and EHR templates.
Electronic Health Record Templates
A narrative summary of state laws concerning electronic health records and requirements for security, storage and deposition of records.
Mental Health Intake & Evaluation Forms
Background information, basic medical history and current functioning (such as mood and thought processes) needed for the intake process.
Describe treatment modality, goals and response, as well as the follow-up plan in this format for patients.
Provide a list of treatments provided, discharge impressions and suggested follow-up care when terminating care with a patient.
Date created: April 2016