Some General Record Keeping Guidelines
Law and ethics require that we exercise due diligence in keeping
confidential and secure the records of all of our professional contacts.
Licensing boards, attorneys, and judges expect us to comply with case law,
professional ethics, and administrative regulations. Our confidential notes
are considered a limited access public record that must exist (1) for the
purpose of aiding the treatment by refreshing our memories on important
material, (2) for informing other professionals who may subsequently be
involved with the client, (3) for protecting ourselves and our profession
against accusations, and (4) for giving ourselves credibility in the event our
case records are ever opened for any reason. Despite the 1996 Redmund
v. Jaffee U. S. Supreme Court Ruling and despite the 1996 federal HIPPA
laws regarding the absolute privacy of Psychotherapy Notes, there are still
many reasons why our records might be forced opened by a licensing
board or judge and we need to be prepared by having kept adequate notes.
Ethical codes and laws are uniform in requiring that notes be made
that are appropriate to the nature of our practice and that reflect the nature
of each professional contact. As of January 1, 2000, the California
legislature has acted to define as unprofessional conduct the failure to keep
records that are consistent with sound clinical judgment, the standards of
the profession, and the nature of the services rendered. But, fortunately,
there are few other fixed standards regarding records because
psychotherapy practice is so diverse in nature.
Use your professional discretion when determining what kinds of
notations are to be made. For example, a psychoanalytic practitioner
seeing an intact client four times a week may routinely note only a few
themes or dreams, whereas a forensic examiner doing interviewing and
testing with highly unstable clients in controversial court cases will need
detailed and accurate notes at every point. Here are a few general
1. Make some kind of written note in your files regarding each and
every client contact.
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2. Maintain your record keeping system in chronological order so
there can never be a question of the record having been rearranged or
altered in any way. Don’t fudge on this or think you can get away with
anything! Altering records is a serious criminal offense. Handwriting
experts can testify whether or not notes were made at the same time and
computer experts have ways of ascertaining if there have been deletions or
additions on your disks—so play it safe. You may cross things out with a
line, alter statements, or make insertions freely, as long as you initial and
date the changes and as long as the original is left intact and readable for
later legal review.
3. Consider using a spiral notebook with one page for each client,
with your notes flowing continuously on both sides. The page can then be
removed and filed, and another page begun. If you carry the notebook
around with you, use only first names or code names until the pages are
4. One system involves the use of the Cross electronic notepad,
which keeps dated notes in your hand that can be downloaded onto your
computer and then cut and pasted into the client’s security-coded file
and/or printed out for hardcopy filing. Then you have your ongoing
handwritten original that an officer of the court could inspect to verify the
chronology if questioned as well as a computer-generated set of notes on
each client. I then delete the notes on my hard disk and record over them,
thus making it more difficult for the disk to be decoded in case of theft of
5. Another currently evolving system is the Evernote software by
Microsoft that allows you to write on your computer screen in hand or by
keyboard and tag each note with a code name for easy retrieval and
printing. Following printing the notes should be deleted for security
6. Accurate voice recognition systems are becoming perfected
(the best may be Dragon) and point toward another potential way of note
keeping. This allows your to simply talk into your computer after each
session or at the end of the day and have your notes immediately ready for
printing. Colleagues who now use Dragon 10 assure me that the number
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of hours required to train the computer to recognize the way you say things
is well worth the time and effort spent.
7. If you are using a word processor and/or a voice recognition
program, make certain that you exercise due diligence in protecting files
with passwords and keeping all electronically stored materials under lock
and key. Be aware that computer experts can easily break codes and can
detect alterations on hard drives.
8. Audio and video cassettes are not only cumbersome to store but
are also at risk of being lost or stolen until they are destroyed. If you record
sessions to review or for supervision, consider using only one cassette or
disc for each client, continually over-recording or over-writing it.
9. When you go over documents that the client has signed, such
as informed consents and client information forms, mark the important
items and make notes in the margin of your questions and discussion with
the client. Initial and date the notes.
10. Never take identifiable confidential material from your office
unless it is enclosed in a large self-addressed and generously
stamped envelope marked “Confidential medical records: Drop into any
mailbox or call (your number).” You could be mugged or in an accident,
and your case files could go astray.
11. Most of the time we can keep our note taking to a minimum as
long as we briefly reference all important issues that come up. On the one
hand, we wish to protect our client’s and our own privacy by not extensively
noting the details. But on the other hand, many clients keep journals and
write notes about what they believe you did or said (or didn’t do or say). If
their record is examined and you have no notes on the matter, your
testimony from memory is highly suspect compared to journal notes
supposedly written at the time by clients. Your notes should contain at
least a brief clarifying statement.
12. Authorities differ on how to best handle documentation of
discussions and events that could be construed as dangerous or
incriminating to the therapist. For example, the standard of care that
attorneys attempt to hold us to is that with suicidal clients we do a written
suicidality assessment before allowing the client to leave our office. But
having documented such an assessment in the record just before a serious
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or successful suicide attempt, we are in a position to be held liable for a
faulty assessment or for a failure to act to prevent the attempt. In such
situations we are in a bind, and our best professional judgment is required.
13. Do not keep multiple sets of notes. All of your notes will be
subpoenaed and you will be asked under oath to testify that you have no
other records. Falsifying or withholding parts of the record is a criminal
14. Therapists sometimes keep a personal journal or make notes
for other personal purposes (such as publishing) in which (de-identified)
client material may be referenced. If you keep this kind of personal journal,
be certain the material you put in it could never be construed as a client
record or an attempt to evade the case record. If you mention the
existence of such personal notes to your attorney or in court you will be
required to produce them.
15. At all important documentation junctures (such as a change of an
aspect of informed consent, a release of information, a letter structuring
expectations or limitations, or a letter stating why you are terminating the
client), explain to clients that the state requires certain kinds of paperwork
be kept in your files and that you need their signature or initials
acknowledging that they have received (and discussed with you) the
document in question. You may wish to use the metaphor of signing for a
traffic ticket—their signature simply indicates for the record that they have
16. If your client refuses to abide by any one of your treatment
requirements such as going for a medical/psychiatric consult, attending a
12-step group, or signing for receipt of a document, you must consider
terminating therapy for non-compliance rather than putting yourself at risk.
Most clients are aware of the liability conditions that we all live under and
are willing to cooperate with you. Those who are not aware of liability
factors or who wish to put you in a dangerous liability position constitute a
17. Document carefully all unusual events, interventions, and
contacts, all irregular contacts such as cards, letters, e-mails, phone calls,
gifts, physical contact, unscheduled meetings, and any locations in which
you see the client other than in your regular consultation room. Be sure to
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include how the event or request came up, what your therapeutic intent
was in the way you handled it, how the interaction was processed at the
time (possibly giving a GAF score), your follow-up discussions and
understanding with the client, your understanding of the transference and
resistance memories involved, your countertransference reactions (simple,
brief, and labeled as such), and the results of any consultations you may
have sought on the matter.
18. In your notes predict possible transference developments that
could turn sour and get aimed at you. That you saw the danger developing
ahead of time and even attempted to discuss the problem with your client
and/or consultant demonstrates thoughtfulness, care, and responsibility.
When serving as an expert witness I cull through the case notes, carefully
looking for all unusual events that might be telling in terms of how the deep
dynamics that unfolded in the treatment have become mirrored in the
accusation. I am ecstatic when I find an occasional note that a particular
conversation seemed to point toward a transference distortion and no
doubt reflects the kinds of misunderstanding, trauma, or abuse the client
experienced in his or her family of origin.
19. There are conflicting opinions about how personal or
countertransference disclosures are best handled and documented. Be
judicious in what you say, both to your client as well as in your notes, as
disclosures can easily be misunderstood or distorted and used against you.
If we believed our clients would be cured of anything by our disclosing
personal information, we would hand out our life story at the first session!
But we don’t believe that. And there is wide variation among therapists
regarding self-disclosures and how they may or may not be seen as helpful
in the therapeutic process. If you work relationally and choose to make
disclosures then in your notes simply state that certain feelings naturally
came up on your part as a result of the interaction with the client and that
they were discussed with the client with a therapeutic purpose in mind.
State the obvious in your notes, but leave out any details or complexities
that could be easily misconstrued. Record simply and in your own terms
minimum, state what feelings came up and how they were discussed.
Document, as usual, your therapeutic intent, the process of the discussion,
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the outcome, and your follow-up with the client. Obviously gratuitous
disclosures that have no therapeutic purpose should be avoided.
20. Using countertransference as a working tool, which many
therapists have good reasons to do, requires that you make some clear
statement early in the record of how and why you do so. Thereafter,
be explicit in stating the therapeutic intent, process, outcome, and follow-up
of the countertransference disclosure, but be professional and to the point.
Then when you are accused of violating the client’s boundaries by sharing
all of your personal problems on a certain date, at least you have a
responsible note that you can use as the basis of your explanations.
21. When contemplating doing something unusual in therapy or when
making notes about something you don’t ordinarily do, always ask yourself
a. What is the therapeutic intent?
b. How would peers view this?
c. How would I view this if another therapist were doing it?
d. How would lay people view or be able to understand this?
Some General Record Keeping Guidelines