Record Keeping in Psychotherapy & Counseling

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

General Resources

• Codes of Ethics on Record Keeping
• Record Keeping Guidelines
• Ethics Codes On Record Keeping and Informed Consent In Psychotherapy
• Book: Record Keeping in Psychotherapy and Counseling
  • Using your computer’s encryption software
• HIPAA and Record Keeping
• Confidentiality:
  • Codes of ethics
  • Guidelines
  • Tarasoff Update, CA
  • Ewing v Goldstein
• Tips for Writing Clinical Notes:
  • Part I
  • Part II
  • Part III

Professional Organizations Guidelines

• APA Record Keeping Guidelines of 2007. The most authoritative document on record keeping for psychologists

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Record Retention Requirements

• Record Keeping in 50 States
• California record retention laws
• APA Record Keeping Guidelines for Psychologists states: “In the absence of a superseding requirement, psychologists may consider retaining full records until 7 years after the last date of service delivery for adults or until 3 years after a minor reaches the age of majority, whichever is later.”
• Psychologists in WA

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Clients’ Requests to Review and/or Amend Their Records

• CA: Patients’ right to access their medical records CA Health and Safety Code § 123100-123149.5
• Instruction to patients on the Medical Board:23100 through 123149.5. The laws which authorize access to your records are available on the Internet and you might wish to review them for information about time lines a physician has to meet and the fees he or she may charge to provide the records. You can view these laws on the California Legislative Information website.
• Medical Board of CA: Frequently Asked Questions Regarding Medical Records

Correcting/Amending and Altering Clinical Records

• Altering or Correcting Clinical Records
• Amending/Correcting Records, by Richard Leslie, J.D.
• The medical record: A legal document – Can it be corrected?

References

• Allan, A., & Allan, M. M. (2016). Psychologists’ collection and management of clients’ information: An ethico-legal perspective. Psychiatry, Psychology and Law, 23(6), 826-841. http://dx.doi.org/10.1080/13218719.2016.1160745
• Barnett, J. E., & Molzon, C. H. (2014). Clinical supervision of psychotherapy: Essential ethics issues for supervisors and supervisees. Journal of Clinical Psychology, 70(11), 1051-1061.DOI:10.1002/jclp.22126
• Bond, T., & Mitchels, B. (2015). Confidentiality & record keeping in counselling & psychotherapy (2nd Ed.). Los Angeles, CA: SAGE.
• Bradford, L., & Stevens, B. (2013). What’s in the file? Opening the drawer on clinical record keeping in psychology. Australian Psychologist, 48(3), 178-187. DOI:10.1111/j.1742-9544.2012.00080.x
• Bradshaw, K. M., Donohue, B., & Wilks, C. (2014). A review of quality assurance methods to assist professional record keeping: Implications for providers of interpersonal violence treatment. Aggression and Violent Behavior, 19(3), 242-250. https://doi.org/10.1016/j.avb.2014.04.010
• Christie, C. D., Bemister, T. B., & Dobson, K. S. (2015). Record-informing and note-taking: A continuation of the debate about their impact on client perceptions. Canadian Psychology/Psychologie canadienne, 56(1), 118-122. http://dx.doi.org/10.1037/a0037860
• DeLettre, J. L., & Sobell, L. C. (2010). Keeping psychotherapy notes separate from the patient record. Clinical Psychology & Psychotherapy, 17(2), 160-163. DOI:10.1002/cpp.654
• DiCarlo, R., & Garcia, Y. E. (2016). Electronic record keeping and psychotherapy alliance: The role of concurrent collaborative documentation. In S. Tettegah, & Y. E. Garcia (Eds.). Emotions, Technology, and Health (pp. 63-82). San Diego, CA: Elsevier.
• Drogin, E. Y., & Armontrout, J. A. (2017). Recordkeeping in private practice. In S. Walfish, J. E. Barnett, & J. Zimmerman (Eds.), Handbook of private practice: Keys to success for mental health practitioners (pp. 66-77). New York, NY: Oxford University Press.
• Elhai, J. D., & Frueh, B. C. (2016). Security of electronic mental health communication and record-keeping in the digital age. The Journal of Clinical Psychiatry, 77(2), 262-268. DOI: 10.4088/JCP.14r09506
• Fors, M., & McWilliams, N. (2016). Collaborative reading of medical records in psychotherapy: A feminist psychoanalytic proposal about narrative and empowerment. Psychoanalytic Psychology, 33(1), 35-57. http://dx.doi.org/10.1037/pap0000019
• Larrison, C. R., Xiang, X., Gustafson, M., Lardiere, M. R., & Jordan, N. (2017). Implementation of electronic health records among community mental health agencies. The Journal of Behavioral Health Services & Research, 1-10. doi:10.1007/s11414-017-9556-9
• Luepker, E. T. (2003). Record keeping in psychotherapy and counseling: Protecting confidentiality and the professional relationship. New York, NY, US: Brunner-Routledge.
• Lo, C. L., & Wadsworth, J. (2014). The impact of novice counselors’ note-taking behavior on recall and judgment. Rehabilitation Research, Policy, and Education, 28(3), 169-182. DOI:https://doi.org/10.1891/2168-6653.28.3.169
• Pope, K. S. (2015). Record-keeping controversies. Canadian Psychology/psychologie canadienne, 56(3), 348-356. http://dx.doi.org/10.1037/cap0000021
• Purves, D. (2015). The ethics and responsibilities of record keeping and note taking. In R. Tribe, & J. Morrissey (Eds.). Handbook of professional and ethical practice for psychologists, counsellors and psychotherapists (2nd Ed. pp. 82-92). New York, NY: Routledge.
• Routledge, C. (2015). Ethical standards in clinical psychology: Maintaining integrity, record keeping and confidentiality. Journal of Applied Psychology and Social Science, 1(1), 15-27. Retrieved from: http://194.81.189.19/ojs/index.php/apass/article/view/210
• Steinfeld, B. I., & Keyes, J. A. (2011). Electronic medical records in a multidisciplinary health care setting: A clinical perspective. Professional Psychology: Research and Practice, 42(6), 426-432. http://dx.doi.org/10.1037/a0025674
• Tansel, A. U. (2013). Innovation through patient health records. Procedia-Social and Behavioral Sciences, 75, 183-188. https://doi.org/10.1016/j.sbspro.2013.04.021
• Wiarda, N. R., McMinn, M. R., Peterson, M. A., & Gregor, J. A. (2014). Use of technology for note taking and therapeutic alliance. Psychotherapy, 51(3), 443-446.http://dx.doi.org/10.1037/a0035075

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