Record Keeping in Psychotherapy and Counseling

Introduction. Purposes of Clinical Records. Documenting Informed Consent. Societal, Legal, and Ethical Bases for Informed Consent. Key Questions to Consider in Documenting Informed Consent. Types of Documentation That Show Informed Consent. Case Example. Summary. Characteristics and Contents of Good Records. Characteristics of Good Records. Key Questions to Answer in Good Records. Essential Contents of Good Records. What Not to Include. Method of Record Keeping: Does it Matter? Summary. Confidentiality and Its Exceptions. Definitions of Terms. Parameters of Confidentiality. Threats to Confidentiality. Ethics Codes' Requirements. State and Federal Laws that Protect Confidentiality. State and Federal Laws' Exceptions to Confidentiality. Other Considerations. Summary. Policies and Procedures for Protecting Confidentiality. Security Measures. Privacy Measures. Protecting Confidentiality of Different Client Populations. Handling 3rd Party Requests for Records. Summary. Retaining and Destroying Inactive Records. Factors to Consider in Determining How Long to Keep Records. Policies and Procedures for Retention and Destruction of Records. Summary. Using Patients' Access to their Records as a Therapeutic Tool . Therapists' Mixed Reactions to Patients Having Access to Their Records. How Records Can Be Used as Therapeutic Tools. Managing Challenging Clinical Situations. Summary. Clinical Supervision Records. Clinical Supervisors' Responsibility. How Clinical Supervision Records Help Supervisors Fulfill their Responsibilities. Confidentiality of Supervision Records. Characteristics and Contents of Supervision Records. Summary. Teaching Record Keeping. How Teaching Record Keeping Helps Supervisors and Supervisees. Methods for Teaching Record Keeping. Summary. Psychotherapists and Records in the Legal System. Therapists and the Adversarial Process. Defining One's Role . Handling Attorneys' Requests, Subpoenas, Court Orders, and Search Warrants. After Becoming Involved in a Legal Case, Now What? Preparing for Deposition or Courtroom Testimony. Testifying. Managing Clinical Issues During Legal Cases. Summary. Preparing for Records Before Interruptions or Closures of Psychotherapy Practices. Clinical, Ethical, and Legal Reasons for Having Plans for Records
II. Procedures that Promote Continuity of Care. Summary. Epilogue. References. Appendices. Appendix A: Excerpts of Ethical Statements on Informed Consent from Mental Health Professions'. Appendix B: Sample Client Information Form. Appendix C: Sample Treatment Plan Form. Appendix D: Sample Revised Treatment Plan Form
Appendix E: Sample Closing Summary Form. Appendix F: Sample Face Sheet, Authorization of Assignment of Insurance Payments to Therapist, and Authorization of Release of Billing Information to 3rd Party Payor. Appendix G: Sample Consent for Treatment of Minor Child Form. Appendix H: Sample Record of Non-Routine Disclosures Form. Appendix I: Sample Authorization of Release of Information. Appendix J: Excerpts of Ethical Statements on Confidentiality from Mental Health Professions. Appendix K: Sample Clinical Supervision Contract. Appendix L: Sample Informed Consent Statement for Mental Health Evaluation in Personal Injury Case Form. Appendix M: Sample of Letter from Therapist to Judge in Child Custody Case. Appendix N: Organizations to Contact for Further Information about Forensics. Appendix O: Ethical Statements on Record Retention and Destruction from Mental Health Organizations. Appendix P: Additional Excerpts of Ethical Statements on Continuity of Care from Mental Health Organization. Index