- It helps therapists provide quality care by providing therapists with continuity where they do not need to rely on their memory to recall details of their patients' lives and the treatment provided.
- Not keeping any records is below the standard of care, is unethical and, in many states, illegal.
- In case of civil, criminal or administrative litigation, it is often not the therapist's word against the client's, but the client's word against the psychotherapy records. Many boards make the decision of whether to pursue a case based on experts who develop their opinion from reading the clients' complaints and the therapists' records but not necessarily interviewing the therapists themselves.
- In case the treating therapist becomes disabled, dies or cannot continue to provide care, records can help the next treating therapist with information and the clients with continuity.
- Store hard copy records in a safe, locked place that is reasonably protected from theft, intrusion, fire, earthquake, water damage and unauthorized access.
- Protect your computer records by use of password, virus protection, firewall and access log. Backup regularly, and store your backup disks off site in a secure location. Print hard copies of very important documents and use access log if necessary.
- Enter relevant information in the clinical records for each session and each meaningful contact, including important phone calls. Include date and type of service and fees, payments and copies of third party billing.
- Make sure that the records include basic demographic information, mental status exam and diagnosis or presenting problem (does not need to be DSM diagnosis, can be familial, developmental, etc.), fee agreement and treatment plan. If relevant, include risk factors, medical and other issues relevant to treatment, collateral information and request for information.
- Before treatment starts present clients with Office Policies and Informed Consent forms, which include information on limitation of confidentiality, fees, third party billing, client's rights, cancellation policies, etc. For detailed information on what may be included in the Office Policies and Informed Consent, click here.
- Update your treatment plans and report on progress or lack there of, as necessary. Treatment plans usually include: Presenting problem, Dx or what you are treating, goals of treatment, interventions or means to achieve these goals, the theoretical, rational or research base for your interventions, referrals, if applicable. (For a complete Treatment Planning Manual, click here).
- Records should reflect your competence, thoughtfulness, decision-making ability, capacity to weigh available options, rational for treatment selection and knowledge of clinically, ethically and legally relevant matters.
- Appropriately document special occurrences, important telephone calls, emergency, dangerousness, mandated and other reporting, consultations, testing, referrals, contact with family members, etc.
- Make sure that your records include the following forms:
- Office Policies and Agreement for Treatment
- Clients' demographic information, which includes how to reach them in emergencies
- Treatment Plan
- HIPAA forms, as applicable. For HIPAA information, click here.
- When applicable, Consents to release information and Consent to treat a minor, test data, medical or educational reports and any relevant collateral data
- Informed consent in forensic and custody evaluations or any other situation that requires such consent
- Summary of termination, who initiated it, for what reason, what was achieved, any follow-up information, and referrals may be necessary. Include copies of follow-up letters, especially when clients terminate prematurely or when managed care inappropriately stops authorizing additional sessions.
- Because no records are immune from disclosure, be careful in your documentation and do not include clinically superfluous details that can cause unnecessary harm for clients or others, if they are disclosed or become public.
- Document, as applicable, give the clinical rational and, when appropriate, ethical considerations for:
- Gifts from clients, therapists or from third party to therapists, loans of books or CDs and bartering arrangement
- Extensive use of touch or self-disclosure
- Recording or videotaping of sessions
- Out-of-office experiences, such as home visits, attending weddings or funerals, going on hikes, taking a client to a medical appointment, adventure therapy and clinically meaningful incidental/chance encounters
- E-therapy, phone therapy or any other telehealth practices, including a special disclosure if these practices are the basic mode of therapy.
- Dual relationship: The nature, extent, etc.
* These guidelines are meant to be aspirational and general, as they may not apply to certain situations, clients and settings.
Online Resources:
- American Psychological Association. (1993). Record keeping guidelines. American Psychologist, 48, 984-986. Click here.
- Codes of Ethics on Record Keeping, click here.
- Online course for CE Credits on Record Keeping, click here.
- Essential Clinical Forms, 53 ready-to-use forms, click here.
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