Record Keeping Guidelines
For Psychologists, Counselors, MFTs, Social Workers
In Private Psychotherapy and Counseling Practice*
By Ofer Zur, Ph.D.
- Good records are the primary proof of quality of care.
- Keeping psychotherapy records is part of the standard of care.
- Assume that no records are immune from disclosure.
- Never alter records. Ways to correct (not alter) records
- Follow state, federal, professional organizations and HIPAA guidelines for record keeping.
- Good records help 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.
- If the treating therapist becomes disabled, dies or cannot continue to provide care for other reasons, clinical 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 clinically relevant and meaningful information in the clinical records. Detail clinically meaningful contacts, including important phone calls and important or clinically significant collateral contacts. Include in records the date and type of services provided, fees, charges, payments, balances 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. Detailed information on what may be included in the Office Policies and Informed Consent
- Update your treatment plans and report on progress, or lack thereof, 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.
- 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.
- Do not repeat the same verbiage or same notes (known as “cloning”) for several consecutive sessions. Copying and pasting the same notes session after session may reflect that the clinical notes do not reflect the dynamics and content of the therapeutic process. It may also result in reimbursement problems with Medicare and other insurance companies, in case of audit by the insurance companies. Generally, repeating exactly the same notes for session after session is likely not to reflect well on your clinical competency and sincerity in the (rare) cases that you are investigated by your licensing board.
- If you are using a checklist, make sure that you add some narratives to the records of most or all sessions that reflect more precisely what was covered in the session.
- SOAP (an acronym for subjective, objective, assessment, and plan) and DAP (an acronym for Data, Assessment (and Response), and Plan) can be helpful options in record keeping.
- 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. HIPAA information
- Informed consent in forensic and custody evaluations or any other situation that requires such consent
- When applicable, Consents to release information and Consent to treat a minor, test data, medical or educational reports and any relevant collateral data
- Summary of termination: Provide information on who initiated the termination and for what reason and what was or was not achieved. If necessary, add follow-up information and referrals.
- Retain records as long as it is legally mandated or, when applicable, take into consideration institutional requirements, professional organizations’ guidelines, professional codes of ethics, or other relevant mandates. (See California Law Records Retention) Generally, there are no legal requirements to maintain any records beyond the required time. However, therapists must take into consideration the context of therapy and the potential need for records in the future, as well as the potential risk of maintaining outdated or obsolete records for long periods of time. More information on how long to keep records and what should be kept after the deadline
- 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
- 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.
- 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
* These guidelines are meant to be aspirational and general, and may not apply to all situations, clients and settings.
- Codes of Ethics on Record Keeping
- Record keeping of Phone Messages, Emails and Texts
- Online course for CE Credit Hours on Record Keeping
- Essential Clinical Forms, 60 ready-to-use forms