- 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.
- 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:
i. Office Policies and Agreement for Treatment
ii. Clients' demographic information, which includes how to reach them in
emergencies
iii. Treatment Plan
iv. HIPAA forms, as applicable. HIPAA information
v. Informed consent in forensic and custody evaluations or any other situation that
requires such consent
vi. When applicable, Consents to release information and Consent to treat a minor,
test data, medical or educational reports and any relevant collateral data
vii. 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.
viii. 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
ix. 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.
x. 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.
xi. Document, as applicable, give the clinical rational and, when appropriate, ethical
considerations for:
xii. Gifts from clients, therapists or from third party to therapists, loans of books or
CDs and bartering arrangement
xiii. Extensive use of touch or self-disclosure
xiv. Recording or videotaping of sessions
xv. E-therapy, phone therapy or any other telehealth practices, including a special
disclosure if these practices are the basic mode of therapy.
xvi. Dual relationship: The nature, extent, etc.
xvii. 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.
Titany answered the question on September 13, 2021 at 11:31