Record Keeping Made Simple
By Zur Institute
Gone are the days when keeping records was a voluntary task. Today, keeping accurate, adequate and timely records is a critical task for all psychotherapists, MFTs and counselors. However, keeping records should neither be a huge burden, nor take too much of therapists’ time and energy.
Why Do We Keep Records?
- In order to document and provide the primary proof of meeting the standards of care of our profession
- To help clinicians with continuity of care
- To promote continuity of care in a case when a client needs to see a new provider due to their therapist’s relocation, illness, death or other reasons
- Records are mandated by most professional organizations’ codes of ethics
- Records are the primary evidence used by clinicians in civil and administrative hearings. Oftentimes in litigation, it is not therapists’ words against their clients’ words. Rather, it is clients’ words against the clinical records.
Record Keeping: A Recap
- Follow state, federal, professional organization, hospital, clinic or institution guidelines for record keeping.
- Make sure that the records include basic demographic information, initial mental status exam, diagnosis or presenting problem (doesn’t need to be DSM diagnosis), fee agreement and treatment plan.
- Enter relevant information in the clinical records for sessions and meaningful email, phone or other communications.
- Records should include the dates of service provided, fees, payments, third party billing, etc.
- Never alter records.
- Store hard copy records in a secure, locked place that is reasonably protected from unauthorized access.
- Protect your computer records with passwords, virus protection and a firewall. Backup regularly and store your backup safely.
- Assume that no records are immune from disclosure. Therefore, be careful in your documentation and do not include clinically superfluous or irrelevant information that can cause unnecessary harm to clients or others if it is disclosed or becomes public.
- If relevant, include risk factors, medical and other issues relevant to treatment, collateral information and requests for information.
- Before treatment starts present clients with Office Policies and Informed Consent forms, which include information on limitation of confidentiality, fees, use and vulnerability of emails, third party billing, client’s rights, cancellation policies, social media policies, etc. Office Policies are provided with the Record Keeping Online Course and are also included in the Essential Clinical Forms.
- Update your treatment plans and report on progress, or lack thereof, as necessary.
- Records should reflect your competence, thoughtfulness, decision-making process, rationale for treatment selection, and knowledge of clinically, ethically and legally relevant matters.
- Document special occurrences, important telephone calls, emergencies, dangerousness to self or others, mandated reporting, consultations, testing, referrals, contact with family members, etc.
- As applicable, document the clinical rationale and risk-benefit analysis and ethical considerations for gifts, bartering, dual relationships, extensive use of self-disclosure, email communication or touch, recording or videotaping of sessions, home visits, E-therapy, etc.
- Provide clinical rationale for use (or non-use) of emails, Internet communication and social media and document accordingly.
- Make sure that your records include forms, such as consents and authorizations, emergency contacts and, when applicable, HIPAA forms, test data, medical or educational reports and any relevant collateral data, forensic and custody evaluations, informed consent, etc, all available as part of the Essential Clinical Forms.
- Include a summary of termination, including who initiated it, for what reason, what was achieved, and any follow-up information and referrals that may be necessary.