Record Keeping in Psychotherapy & Counseling: Ethical, Legal and Clinical Issues

Proper record keeping is an area of practice that is confusing and unclear to many practicing psychotherapists and counselors. What to put in the records? How long to keep records? Is it better to keep records online or on the cloud? What to do if I’m subpoenaed? When can I dispose of records, and what’s the best way? These are some of the pressing questions around record-keeping that therapists face. The time to get answers is now, before legal or clinical issues become acute and the records are under scrutiny. This course teaches best practices for record keeping, relevant laws and regulations, how to respond if issued a subpoena, and the best ways to deal with third-party payers who request records, among many other relevant issues. Course fee includes 60 most important clinical forms.

This intermediate level course begins with an introductory section on record-keeping guidelines. This section includes a text overview and audio interview with ethicist and scholar, Dr. Michael Donner, chair of the California Psychological Association (CPA) Ethics Committee (transcript provided). The second section contains an article on informed consent and the process of obtaining and retaining informed consent throughout treatment. The third section contains an article on keeping records of electronic communication, such as voicemails, emails, and text messages. Also discussed are several options for keeping records online. The fourth section gives therapists resources for responding to subpoenas in an ethical, legally compliant, and clinically appropriate manner. The fifth section covers record retention: how long to keep records and relevant California law. The sixth section discusses risk management and what belongs in the clinical records, over the course of several articles. The seventh section includes a full set of clinical forms, on topics including termination, informed consent, office policies, treatment plans, professional will, and much more. Additional resources and references are provided for further study, but they are not part of the course.