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

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All materials are available as audios with transcripts.

Developed by Ofer Zur, Ph.D.

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This course includes 60 Essential Clinical Forms, ready to use Updated 2020. The forms are valued at $99, making this course an excellent deal.

Course fulfills the California and other states' ethics and law requirements.
Course may qualify for insurance discount. Check with your insurer.

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

General Course Description

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.

Educational Objectives:

    This course will teach the participant to

  • Learn the current laws and regulations regarding record keeping.
  • Discuss the issues involved in keeping records electronically online.
  • Evaluate current record-keeping practices.
  • Summarize appropriate ways to dispose of records.
  • Prepare to respond to subpoenas in an appropriate manner.
  • Utilize clinical forms in the psychotherapy practice.

Course Syllabus:

  • Overview of documentation and record-keeping
  • Reasons to document
    • Clinical
    • Ethical
    • Legal
  • What belongs in clinical records
    • Client information
    • Clinical developments
    • Termination information
    • Testing, crisis and other relevant information
  • Relevant ethical issues
    • Clinical matters
    • Principles
    • Codes
    • Standards
  • Legal issues (including CA law)
    • HIPAA
    • How long to keep records
  • Subpoenas
    • How to respond
    • Protecting clients’ confidentiality
    • Giving the minimum information needed
    • Patriot Act – Special circumstances
  • Risk management
    • How records can help
    • Keeping appropriate records
  • Effective documentation strategies
    • Retention
    • Storage
    • Electronic Storage
    • Disposal
  • Essential forms and templates
  • Codes of Ethics
    • Guidelines from professional associations
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Cost: $119

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