Record Keeping in Psychotherapy and Counseling

Ellen T. Luepker, MSW, BCD, is a licensed psychologist and clinical social worker in private practice, and an instructor in the University of Minnesota School of Medicine, Department of Psychiatry. She provides training to mental health professionals nationally and abroad on ethical issues and consultation to regulatory boards and attorneys regarding malpractice cases. She was honored by the National Academy of Practice as a Distinguished Practitioner, by the National Association of Social Workers as a Social Work Pioneer, and received Smith College’s Day-Garrett Award for her contributions to professional standards in mental health care.

Introduction. Purposes of Clinical Records. Documenting Informed Consent. Characteristics and Contents of Good Records. Confidentiality in an Electronic Age. Exceptions to Confidentiality. Developing Policies and Procedures for Protecting Confidentiality and Managing its Exceptions in an Electronic Era. Boundary Challenges: Impact of Electronic Communication on the Therapeutic Relationship. Retaining and Destroying Inactive Records. Using Patients' Records as Therapeutic Tools. Clinical Supervision Records. Teaching Record Keeping. Psychotherapists and Records in the Legal System. Planning for Interruptions or Closure of Psychotherapy Practices. Epilogue. Appendix A: Sample Client/Patient Information. Appendix B: Sample Treatment Plan Form. Appendix C: Sample Revised Treatment Plan Form. Appendix D: Sample Closing Summary Form. Appendix E: Sample Consent for Treatment of Minor Child Form. Appendix F: Sample Authorization for Release of Information Form. Appendix G: Sample Clinical Supervision Contract. Appendix H: Sample Informed Consent Statement for Mental Health Evaluation in a Personal Injury Case. Appendix I: Sample Letter from a Psychotherapist to a Judge in a Child Custody Case. Appendix J: List of Selected Professional Organizations and their Web Sites. Appendix K: Contents of Accompanying CD.