Record keeping for psychologists in Quebec: what the Order requires

Record keeping for psychologists in Quebec is the duty of every member of the Ordre des psychologues du Québec (OPQ) to keep a record for each client, keep it up to date, retain it and protect its confidentiality. The core text is the Règlement sur la tenue des dossiers et des cabinets de consultation des psychologues (regulation on the keeping of records and consulting rooms, CQLR c. C-26, r. 221). It is still in force: LégisQuébec shows it as up to date to 1 July 2026. A 2025 decision of the Order amended two of its sections.

Here is what it requires, section by section, along with client access, ceasing to practise, and what Law 25 changes if you use an AI note-taking tool hosted outside Quebec.

Which texts apply in 2026

Three texts govern the record, all read on LégisQuébec in their version up to date to 1 July 2026:

• regulation C-26, r. 221, adopted in 1992 (Order in Council 448-92) and not replaced; OPQ decision 2025-918 amended its sections 13 and 21;
• the Code de déontologie des psychologues (code of ethics, C-26, r. 212), for client access (sections 20 and 21);
• the Règlement sur les dossiers d'un psychologue cessant d'exercer sa profession (records of a psychologist who ceases to practise, C-26, r. 216).

If you work in an institution of the health and social services network, the beneficiary's record held by the institution counts as your record, if you can enter the section 3 information in it and its confidentiality is ensured. Sections 8 to 10 then do not apply to you (section 12). You sign or initial every entry. Within another organization, you may place your information in its records if their confidentiality is ensured, and you sign or initial what you enter (section 13).

What the record must contain (section 3)

• the date the record was opened;
• the client's identity: name at birth, sex, date of birth, address, telephone (or, for a business, its details and those of its representative);
• a brief description of the reasons for consultation;
• a brief description of the services provided and their dates;
• the conclusions of the psychological assessment or a description of the intervention programme, and the recommendations;
• notes on the client's progress following the services;
• any document about sharing information with third parties, including the client's signed authorization;
• a copy of any service contract or a description of any special agreement;
• the signature of the psychologist who entered this information.

For a group, section 4 allows a single record for the intervention. Section 5 asks the psychologist to avoid placing in the record any unprocessed raw data, or any unverified information that could harm the client.

Progress notes

The regulation does not set a format. The OPQ's explanatory guide on record keeping (in French, September 2008) gives pointers. Each entry is dated and signed with name and title. The client is identifiable on every page. Notes are written at the time of the events, in a single record per client. The guide counts verbatim transcripts as raw data, and notes that raw data accompanied by its interpretation is no longer raw data.

Progress note template to copy

A suggestion from Delta, built from section 3 and the guide:

• Client: [name or file number]
• Date and service provided: [date], [assessment, psychotherapy…]
• Topics discussed and interventions: [a few sentences]
• Progress against the intervention plan: [progress, difficulties]
• Professional interpretation: [your clinical reading]
• Next steps: [next session, authorized sharing]
• Signature: [first name, last name, psychologist]

More formats are in our clinical document templates.

Retention period: at least 5 years

The psychologist keeps each record for at least 5 years from the last professional service (section 8). The OPQ guide notes this is a minimum. After that, section 9 allows destruction in a way that protects confidentiality. For a digital record, we recommend also deleting copies and backups, and noting the destruction date.

Security and confidentiality

Records are kept in a cabinet the public cannot freely access, locked or otherwise secured (section 7). Computers are allowed if confidentiality is ensured (section 2). For digital records, we recommend the equivalent of a locked cabinet: a strong password, two-factor authentication, encrypted data and backups. The private sector Act also requires reasonable security measures given how sensitive the information is (section 10).

Client access and sharing with third parties

On written request, the psychologist gives access or a copy promptly and no later than 30 days (section 20 of the Code of ethics). Fees stay reasonable, limited to the cost of copying and sending. The psychologist may temporarily refuse access to a piece of information if disclosing it would seriously harm the client's health. The psychologist then gives the reasons, notes them in the record and tells the client how to challenge the refusal. Section 21 lets the client have inaccurate information corrected or add their own comments.

When information is sent to a third party, the psychologist waits 15 days after the authorization is signed. The client may withdraw consent during that time, or waive the delay in an emergency. A note signed and dated by the client goes in the record (section 10 of the regulation).

Ceasing to practise

If you stop practising permanently, you notify the secretary of the Order by registered mail at least 15 days before the planned date (section 2.01 of regulation C-26, r. 216). Either a colleague takes over your records as transferee, under a written agreement sent to the secretary (section 1.05), or you hand your records to the secretary. Within 30 days, the transferee or the secretary informs your clients in writing and publishes a notice twice, 10 days apart, in a French-language daily newspaper (section 2.04).

For a temporary stop, the same rule applies with a provisional custodian (section 3.01). The OPQ offers an agreement form for transfer or provisional custody (in French).

AI note-taking tools: what Law 25 changes

Law 25 amended the Act respecting the protection of personal information in the private sector, which applies to any person carrying on an enterprise. In our view, a private practice generally falls within it; if in doubt, ask a lawyer.

• Section 3.3. Acquiring an information system that handles personal information requires a privacy impact assessment (PIA), proportionate to how sensitive the information is.
• Section 17. Before communicating personal information outside Quebec, a PIA considers sensitivity, purpose, protection measures and the legal framework of the destination. The communication may go ahead if protection is adequate, under a written agreement. This also applies when a provider outside Quebec keeps the information for you.
• Section 18.3. The contract with a provider is in writing and sets out the confidentiality measures.

A tool hosted in France therefore falls under section 17, and the PIA is yours to carry out. The Commission d'accès à l'information publishes a guide to carrying out a PIA (in French, April 2024). It states that without adequate protection, the communication must not take place.

On ethics, section 15, paragraph 5 of the Code requires the client's prior written authorization before making an audio or video record. The texts we read do not say whether live transcription, with no audio file kept, falls within this rule. To be safe, we recommend obtaining written authorization and asking the Order. We also recommend placing the reviewed, interpreted note in the record rather than a raw transcript (section 5). See also our article on professional confidentiality and AI.

What Delta provides, and what stays with you

Delta is the clinical assistant for mental health professionals. During the session, it transcribes what is said; or after the session, you dictate your observations. Delta generates the session report (short summary, detailed summary, topics for the next session) and updates the client's record with a summary of care and the goals being tracked. This helps keep dated, regular progress notes. Delta also drafts letters, certificates and assessment reports.

Data is hosted in France with an HDS-certified host, and AI processing takes place in France. The client's name and identifying details are pseudonymized before the AI step. No audio file is kept. Data is never used to train a model (see does AI train on therapy notes) and is encrypted in transit and at rest. Details are on our security page.

These facts feed into your PIA; they do not replace it. The section 17 assessment, the written agreement, the content of the record and its retention remain your responsibility.

Sources

• Regulation C-26, r. 221 on the keeping of records and consulting rooms by psychologists, LégisQuébec, up to date to 1 July 2026 (official text in French).
• Code de déontologie des psychologues, CQLR c. C-26, r. 212, LégisQuébec, up to date to 1 July 2026.
• Regulation C-26, r. 216 on the records of a psychologist who ceases to practise, LégisQuébec, up to date to 1 July 2026 (official text in French).
• Act respecting the protection of personal information in the private sector, CQLR c. P-39.1, LégisQuébec, up to date to 15 October 2026.
• Commission d'accès à l'information, guide to carrying out a privacy impact assessment (in French), version 3.1, April 2024.