I got a great question from one of my newsletter subscribers a couple weeks ago: What actually goes in the client chart? I'm pretty sure she asked this question because, as you may have discovered, once you dive in to treating clients things aren't so black and white.
I once went to a seminar on electronic risk management and the presenter recommended that if therapists text with their clients about appointments they print out every message and put it in the chart. Now, I tend to lean on the conservative side of the documentation spectrum but that's just crazy (and wasting paper)!
So what do we include, then? Just a consent form and regular notes? Every communication you've ever had with every client... most communication... if so, what needs to be in and what is out?! Like most things documentation, there's no absolute right or wrong. However, the following guidelines can help make the decision a lot easier:
- Signed paperwork- any policies, procedures or anything else you have your client sign should be in their file. If you use electronic record keeping (which I totally recommend!), have clients sign online via a client portal or scan the signed documents into your system.
- Weekly clinical notes- there should be a note for every week you're scheduled to see your client. If you see your clients biweekly or monthly, make a note of that. The key is to make sure all your client's meetings with you are accounted for and there are no gaps in the story of your treatment with them.
- Assessment/intake paperwork- include any documents you have for assessing clients when they start with you. This may be a brief questionnaire as well as things like contact information and other forms you have clients complete when they begin working with you.
- Scheduling summary- Writing regular notes on client sessions is a given but what about when clients cancel or constantly reschedule? I recommend brief notes about that, too. This is especially important in case you ever fall behind in documentation. God forbid you are a month behind in paperwork and can't remember what week Sally Client cancelled her appointment and whether or not you saw Johnny Client on Monday or Thursday five weeks ago... these are the things that are easy to overlook but cause a lot of time and stress figuring out later on. Having a note like "3/20/15- Sally Client cancelled; next appt 3/27/15" can be a big help and will only take you 20 seconds to jot down.
- Insurance information- if you bill to insurance this is critical! Keep a copy of your client's insurance card and any authorizations you receive. Document any conversations you have with the insurance company, as well. Some therapists find it useful to keep this information in a separate "financial folder"... it really just depends on the amount of documentation and whether or not it all easily integrates with your electronic record system.
- Drawings and projects- depending on your clientele and personal style, these may be an integral part of your treatment or something you rarely have clients do. Regardless, this is often precious and valuable for treatment. I'd recommend you keep copies of these things safe (unless it's something meant for the client to take home). That way you can look back on pivotal moments and themes in the therapy journey.
- Outcomes tools- if you use any kind of outcome tool on paper, keep that as part of the client record. Just like drawings and projects, it's vital clinical information for yourself and a great resource when evaluating progress and client strengths.
- Reports- if you write reports for clients, keep a copy (preferably, a digital copy) in their file along with any disclosures of the report. Likewise, if you receive reports from an outside entity (psychiatrist, testing psychologist, etc), that should be in your client's file.
- Outside communication- document consultations you have regarding your client. That may be talking with a parent or other family member, a doctor, psychiatrist, previous therapist, etc. This may also include consultations you have with other therapists, your malpractice insurance, etc. regarding any ethical dilemmas or areas outside your expertise.
- Accounting of disclosures- it's very important to document any time you disclose confidential information about your client. Aside from having a release to do so, document the date and to whom you actually release information. If you're a HIPAA covered entity this is a requirement; if you're not a HIPAA covered entity it is still recommended for both your sake and your client's sake.
One of the few things I recommend you actually don't keep in your client's file is any reports regarding abuse (read more here). These reports often have very sensitive information that your client may not want subpoenaed in a potential court case.
Another thing you want to keep separate from your client's file is process notes. I talk more about what this means in my Private Practice Paperwork Crash Course, but process notes are essentially your own notes as the therapist. These are not required and would be in addition to your regular weekly clinical notes.
Honestly, this list could go on and on with potential scenarios so the key is to always use your clinical judgement. Ask yourself, "is this something related to treatment?" and "Is this something related to my policies and procedures?" If the answer is yes to either, better to keep it as part of the record. And when in doubt, I always recommend you consult with a colleague. You'll likely end up having a great discussion!
Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors.