Record Keeping

 
Timely And Thorough Records:

• Document and provide the primary proof of meeting the standards of care of our profession.
• Help clinicians provide quality ongoing care.
• Are valuable to the next treating clinician for promoting continuity of care whenever a client’s care must be transferred.
• Are mandated by most professions’ ethics codes and most states’ laws.
• Are the primary evidence used by clinicians in civil and administrative hearings.

 
Record Keeping: A Recap

• Follow state, federal, professional organization, hospital, clinic or institution guidelines for record keeping.
• Never alter records.
• Store hard copy records in a secure, locked place that is reasonably protected from unauthorized access.
• Protect your computer records with use of passwords, virus protection and a firewall. Backup regularly and store your backup safely.
• Assume that no records are immune from disclosure. Therefore, 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.
• Enter relevant information in the clinical records for sessions and meaningful contacts, including date, service provided, and fees, payments 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), fee agreement and treatment plan.
• If relevant, include risk factors, medical and other issues relevant to treatment, collateral information and requests 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.
• Update your treatment plans and report on progress, or lack thereof, as necessary.
• Records should reflect your competence, thoughtfulness, decision-making rationale for treatment selection, and knowledge of clinically, ethically and legally relevant matters.
• Appropriately document special occurrences, important telephone calls, emergencies, dangerousness, mandated reporting, consultations, testing, referrals, contact with family members, etc.
• Make sure that your records include forms, such as consents and authorizations, emergency contacts and, when applicable, HIPAA forms, test data, medical or educational reports and any relevant collateral data, forensic and custody evaluations, informed consent, etc.
• Include a summary of termination, who initiated it, for what reason, what was achieved, and any follow-up information and referrals that may be necessary.
• As applicable, document the clinical rationale and, when appropriate, ethical considerations for gifts, bartering, extensive use of touch or self-disclosure, dual relationships, recording or videotaping of sessions, home visits, E-therapy, etc.