What Clinical Notes & Records must be Maintained by Therapists?

Mental health care professionals are increasingly being called into depositions and court hearings to provide records and testimony concerning treatment provided to their clients. Whether you like it or not, clinical notes — including computer files — cannot be fully protected in legal proceedings. Every therapist must keep and maintain clinical notes, in some cases preserving them for seven years for adults and longer for clients who are minors. Professional rules indicate what records must be maintained. In addition, the ethical canons of many jurisdictions, usually stated in guidelines published by the various licensing boards, require that certain records be maintained for each client. These include:

1. The therapist shall base their services on an assessment, evaluation, or diagnosis of the client. The standard suggests that therapists must maintain notes that contain clinical information and the rationale for the assessment, evaluation, and diagnosis of client. It also implies that the treatment plan should be supported by the same factors.
2. The therapist shall evaluate a client’s progress on a continuing basis. All client notes must be maintained and updated throughout the treatment process. Changes to the assessment, evaluation, prognosis, and diagnosis, as well as the treatment plan, should be updated continuously, as long as the client is in treatment. When terminated, the record should record the reason for termination.
3. The therapist shall keep records for each client of the dates and services, types of services, and billing information.
4. The therapist shall not disclose any confidential information but will take reasonable action to inform medical and law enforcement personnel if the professional determines that there is a probability of imminent physical injury to the client or others.

In general, confidentiality is to be protected. However, when there is an imminent threat to the health or safety of another the therapist must, or sometimes, may, alert the police, a medical facility or the client’s family to prevent suicide or great bodily harm. Make sure to consult the statutes in your state and federal HIPAA law to understand both the restrictions and exceptions to the disclosure of protected healthcare information. Practitioners must also keep in mind that the privilege to protect the records belongs to the client. The therapist does not possess the right to refuse to disclose the file if the client and the court determine that it should be made public.