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Record Keeping:

Dotting the i's and Crossing the t's

Clinical Update
By Zur Institute

View a complete list of Clinical Updates.

 

Record Keeping

Proper record keeping helps the clinician with treatment, enhances the quality of care, helps maintain a continuity of care, can protect the clinician in times of lawsuit or subpoena, and helps in the event of the therapist's early death or other impediment to continuing treatment. The standard of care, HIPAA, the Patriot Act, and licensing boards all come into play with regard to good clinical records and related best practices.

Rather than facing licensing board sanctions for inappropriate recording of a psychotherapy session, or for inappropriate storage or disposal of records. . .

Rather than being caught off guard upon receiving a subpoena and unwittingly compromising your client's confidentiality by responding inappropriately . . .

Rather than letting your clinical records with sensitive information fall into the wrong hands. . .

Educate yourself

All this and more is discussed in our revised online course:

Record-Keeping: Ethics, Clinical Work, and the Law

The course includes our best-selling 60 Essential Clinical Forms

Audio introduction to course by Ofer Zur, Ph.D.      Audio File (Transcript)

A must-have for practicing clinicians!

 

 
Did you know?

  • Keeping adequate records is not only helpful to therapists, but is necessary to comply with the standard of care.
  • Like voice messages and phone conversations, if texts or e-mails have clinical significance, they should be noted in the clinical records.
  • In California, psychologists must keep records for adult clients for seven years and MFTs and LCSWs must keep records for adult clients for ten years. Find out the record retention laws in your state.
  • Third party payers do not necessarily have the right to complete access to clinical records.
  • Responding to a subpoena appropriately means more than simply handing over records.
  • It is sometimes acceptable to provide a summary of clinical records in response to a subpoena.
  • Clinical records must include Office Policies - Informed Consent, Biographical Information, Treatment Plan, testing, ongoing clinical notes of sessions, notation of significant contacts between sessions and other essential documents that are available in our 60 Essential Clinical Forms, included in this course.
  • Including e-mails with clinical records is simple and easy.
  • Consent is more than a form to be signed, it is also an ongoing process and dialogue.

 
In order to learn more about how to comply with record keeping standards and regulations and be on the right side of ethics, clinical work, and the law with regard to record keeping, we recommend the following:

  • Take our revised Record Keeping course.
  • If your clinical records are subpoenaed, seek legal consultation before sending records.
  • Include in clinical records the following:
    • Office policies - Informed consent
    • Biographical background
    • Initial assessment and treatment plan
    • Termination information
    • Client homework assignments
    • Related consultations (ethical, legal, clinical)
    • Notes on any dual relationships, bartering, gifts, or extensive out of office experiences.
  • Store records securely for at least the minimum amount of time, as required by law.
  • Consider if there is any reason to keep clinical records past the minimum time and, if appropriate, keep them longer.
  • Dispose of records via incineration or shredding when the time comes.

 
 

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Ofer Zur, Ph.D., Director

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