An Online Course: 
<a class="mi" href="/course/record-keeping/">Record Keeping in Psychotherapy &amp; Counseling: Ethical, Legal, and Clinical Issues</a>
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Table Of Contents
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<li><a class="mi" href="#general">General Resources</a></li>
<li><a class="mi" href="#guidelines">Professional Organizations Guidelines</a></li>
<li><a class="mi" href="#requirements">Record Retention Requirements</a></li>
<li><a class="mi" href="#amend">Clients&#8217; Requests to Review and/or Amend Their Records</a></li>
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<li><a class="mi" href="#correcting">Correcting/Amending/Altering Clinical Records</a></li>
<li><a class="mi" href="/resources/informed-consent/">Informed Consent</a></li>
<li><a class="mi" href="/resources/subpoenas/">Subpoenas</a></li>
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<li><a class="mi" href="#add_ref">References</a></li>
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<a name="general"></a>General Resources
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<li><a class="mi" href="/record-keeping-guidelines/">Codes of Ethics on Record Keeping</a></li>
<li><a class="mi" href="/record-keeping-guidelines/">Record Keeping Guidelines</a></li>
<li><a class="mi" href="/ethics-of-recordkeeping/" target="_blank" rel="noopener">Ethics Codes On Record Keeping and Informed Consent In Psychotherapy</a></li>
<li><a class="mi" href="http://www.amazon.com/Record-Keeping-Psychotherapy-Counseling-Confidentiality/dp/1583913068" target="_blank" rel="noopener">Book: Record Keeping in Psychotherapy and Counseling</a>
<ul>
<li><a class="mi" href="https://personcenteredtech.com/2013/04/05/hipaa-safe-harbor-for-your-computer-the-ultimate-in-hipaa-compliance-the-compleat-guide/" target="_blank" rel="noopener">Using your computer&#8217;s encryption software</a></li>
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<li><a class="mi" href="/hipaa-compliance-kit/">HIPAA and Record Keeping</a></li>
<li>Confidentiality:
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<li><a class="mi" href="/ethics-of-confidentiality/">Codes of ethics</a></li>
<li><a class="mi" href="/online/confidentiality_intro/">Guidelines</a></li>
<li><a class="mi" href="/tarasoff/">Tarasoff Update, CA</a></li>
<li><a class="mi" href="https://digitalcommons.law.ggu.edu/cgi/viewcontent.cgi?article=1926&amp;context=ggulrev" target="_blank" rel="noopener">Ewing v Goldstein</a></li>
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<a name="guidelines"></a>Professional Organizations Guidelines
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<li><a class="mi" href="http://www.apa.org/practice/guidelines/record-keeping.pdf" target="_blank" rel="noopener">APA Record Keeping Guidelines of 2007</a>. The most authoritative document on record keeping for psychologists</li>
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<a class="mi" href="#top">Top of Page</a>
<a name="requirements"></a>Record Retention Requirements
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<li><a class="mi" href="https://telehealth.org/forms/" target="_blank" rel="noopener">Record Keeping in 50 States</a></li>
<li><a class="mi" href="/recording-keeping-ca/" target="_blank" rel="noopener">California record retention laws</a></li>
<li><a class="mi" href="http://www.apa.org/practice/guidelines/record-keeping.pdf" target="_blank" rel="noopener">APA Record Keeping Guidelines for Psychologists</a> states: &#8220;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.&#8221;</li>
<li><a class="mi" href="http://apps.leg.wa.gov/wac/default.aspx?cite=246-924-354" target="_blank" rel="noopener">Psychologists in WA</a></li>
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<a class="mi" href="#top">Top of Page</a>
<a name="amend"></a>Clients&#8217; Requests to Review and/or Amend Their Records
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<li><a href="https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=HSC&amp;division=106.&amp;title=&amp;part=1.&amp;chapter=1.&amp;article=">CA: Patients&#8217; right to access their medical records CA Health and Safety Code § 123100-123149.5</a></li>
<li>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 <a class="mi" href="http://leginfo.legislature.ca.gov/" target="_blank" rel="noopener">California Legislative Information website</a>.</li>
<li><a class="mi" href="http://www.mbc.ca.gov/Consumers/Complaints/Complaints_FAQ/Medical_Records_FAQ.aspx" target="_blank" rel="noopener">Medical Board of CA: Frequently Asked Questions Regarding Medical Records</a></li>
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<a name="correcting"></a>Correcting/Amending and Altering Clinical Records
<ul>
<li><a class="mi" href="/clinical-updates/correcting-v-altering-records/">Altering or Correcting Clinical Records</a></li>
<li><a class="mi" href="http://www.cphins.com/amendingcorrecting-records/" target="_blank" rel="noopener">Amending/Correcting Records</a>, by Richard Leslie, J.D.</li>
<li><a class="mi" href="https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2009/the-medical-record-a-legal-document-can-it-be-corrected" target="_blank" rel="noopener">The medical record: A legal document &#8211; Can it be corrected?</a></li>
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<a name="add_ref"></a>References
<ul>
<li>Allan, A., &amp; Allan, M. M. (2016). Psychologists&#8217; collection and management of clients&#8217; information: An ethico-legal perspective. Psychiatry, Psychology and Law, 23(6), 826-841. http://dx.doi.org/10.1080/13218719.2016.1160745</li>
<li>Barnett, J. E., &amp; 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</li>
<li>Bond, T., &amp; Mitchels, B. (2015). Confidentiality &amp; record keeping in counselling &amp; psychotherapy (2nd Ed.). Los Angeles, CA: SAGE.</li>
<li>Bradford, L., &amp; Stevens, B. (2013). What&#8217;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</li>
<li>Bradshaw, K. M., Donohue, B., &amp; 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</li>
<li>Christie, C. D., Bemister, T. B., &amp; 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</li>
<li>DeLettre, J. L., &amp; Sobell, L. C. (2010). Keeping psychotherapy notes separate from the patient record. Clinical Psychology &amp; Psychotherapy, 17(2), 160-163. DOI:10.1002/cpp.654</li>
<li>DiCarlo, R., &amp; Garcia, Y. E. (2016). Electronic record keeping and psychotherapy alliance: The role of concurrent collaborative documentation. In S. Tettegah, &amp; Y. E. Garcia (Eds.). Emotions, Technology, and Health (pp. 63-82). San Diego, CA: Elsevier.</li>
<li>Drogin, E. Y., &amp; Armontrout, J. A. (2017). Recordkeeping in private practice. In S. Walfish, J. E. Barnett, &amp; J. Zimmerman (Eds.), Handbook of private practice: Keys to success for mental health practitioners (pp. 66-77). New York, NY: Oxford University Press.</li>
<li>Elhai, J. D., &amp; 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</li>
<li>Fors, M., &amp; 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</li>
<li>Larrison, C. R., Xiang, X., Gustafson, M., Lardiere, M. R., &amp; Jordan, N. (2017). Implementation of electronic health records among community mental health agencies. The Journal of Behavioral Health Services &amp; Research, 1-10. doi:10.1007/s11414-017-9556-9</li>
<li>Luepker, E. T. (2003). Record keeping in psychotherapy and counseling: Protecting confidentiality and the professional relationship. New York, NY, US: Brunner-Routledge.</li>
<li>Lo, C. L., &amp; Wadsworth, J. (2014). The impact of novice counselors&#8217; 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</li>
<li>Pope, K. S. (2015). Record-keeping controversies. Canadian Psychology/psychologie canadienne, 56(3), 348-356. http://dx.doi.org/10.1037/cap0000021</li>
<li>Purves, D. (2015). The ethics and responsibilities of record keeping and note taking. In R. Tribe, &amp; J. Morrissey (Eds.). Handbook of professional and ethical practice for psychologists, counsellors and psychotherapists (2nd Ed. pp. 82-92). New York, NY: Routledge.</li>
<li>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</li>
<li>Steinfeld, B. I., &amp; 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</li>
<li>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</li>
<li>Wiarda, N. R., McMinn, M. R., Peterson, M. A., &amp; 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</li>
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Record Keeping

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