Notes and Clinical Records
Most insurance policies and professional associations will have requirements in regard to record-keeping and note-keeping. Please check the requirements of your Professional Indemnity Insurers.
Note Taking
Notes, as the name suggests are memory-jogging notes designed to enable you to join up content between client sessions and to be self-briefed before the client enters their next session. Some styles of therapy encourage comprehensive notes, while others discourage notes, believing that sessions should flow freely and not be contaminated by previous content. This is stylistic.
Record Keeping
Record keeping is for clinical client safety. It includes contracting and assessment forms, reassessment forms, letters written in support of your client, emails between yourself and your client regarding clinical matters, and risk assessment recording of issues of safety which might also appear in notes. These might include declarations of self-harm, suicidal thoughts, other harm, failure to comply with care and treatment plans, inappropriate behaviour, etc.
Record keeping may also include a record of behaviours that might present a risk to the therapist, such as transference causing the possibility of attraction or flirtation, failure to adhere to contracting, and apparent movement towards a confrontation or complaint. These need to be recorded for your own protection and should be taken to your supervisor in the first instance. Be sure to record anything you see fit so as to protect yourself should you need to terminate therapy and refer on or defend yourself from any complaint.
- Members must maintain accurate and respectful documentation of client sessions, ensuring these records are secure and private, except when justified reasons exist for not keeping records. This includes adhering to GDPR and other relevant data protection laws.
- All session records, in any format, require stringent security measures to prevent unauthorised access. Audio or video recordings of sessions necessitate written consent from clients.
- Documentation must be securely archived for specific durations: a general 5 year period post-therapy as suggested by the NCIP, and for minors, until they reach adulthood (18 years of age) plus an additional seven years. Members should also align with any varying requirements from insurance, agencies, or legal regulations.
- Clients should be clearly informed about the handling of their records, including storage, archiving, and the confidentiality practices, typically outlined in client consent forms, adhering to GDPR.
- Members are responsible for granting access to case records in compliance with the Access to Health Records Act 1990, the Data Protection Act 1998, and other relevant legislation. In relationship or family therapy, all adult parties must consent for records to be released, and individual session records must be maintained separately to ensure privacy and adherence to consent protocols.
Combined Method
If you take comprehensive notes, then have a way of highlighting risk issues so that you remember to take them to your supervisor and can access them clearly. The advantage here is that you do not need two formats. However, there is a risk that, in the event of a complaint, your risk assessment records may be “contaminated” by other notes that you might not really want to be discussed, such as personal feelings and countertransference feelings.
Separate Methods
Although more work if you do keep notes, a separate record of perceived risk is “cleaner”, and more specific, and tends to be better evidence that the issue was flagged as unusual and significant by you at the time. As long as you take this to your supervisor and you take appropriate action, there is a clear process of you identifying a threat, taking advice, and taking action. Try to be dispassionate and clinical, in a factual but clear and detailed manner.
Related Data
It is also recommended to keep copies of other media shared such as hypnosis, mindfulness, meditation recordings, handouts, or advice sheets.
Data Protection
Remember that any notes taken on the client are accessible by them under data protection legislation. Be careful therefore with opinions, always assume that the client may read what you are writing.
Questions to Consider
What does my insurance policy require?
Am I updating assessments and how?
Am I clear in contracting in regard to how I take/do not take notes?
If I do not take notes, can I hold enough detail in my mind between sessions?
If I do take notes, does taking those notes interrupt the flow or co-regulation in session?
If I had a complaint from the client “out of the blue”, would I be able to gather all my evidence within a short time period?
Have I reviewed my data protection policy, including registering with the Information Commissioner’s Office (ICO)?
Is my data secure, whether physically under lock and key, or digitally and protected with adequate malware, antivirus, firewall protection, and passwords?
Have I checked ALL devices that might have access, such as smartphones, tablets, and laptops?
If I use a shared space, is the data secure if someone enters the work area?
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