This concise volume examines exactly what is involved in keeping adequate clinical records of individual, family, couple and group psychotherapy. The authors discuss: limits of confidentiality; retention and disposing of records; documentation of safety issues; client access to records; treatment of minors; and training and supervision issues. Throughout the book, legal cases, vignettes and professional commentary help readers to consider legal and ethical issues.
Part II: The Clinical Record
This section contains three chapters. Chapter 3, “Contents of a Good Record,” is the major material covered in this text. It should be noted that the data discussed in Chapter 3 is needed in private practice, in agencies, and in managed care environments. What may differ from one practice situation to another is the model or style used in the various environments. From a record-keeping perspective, Chapter 4 briefly discusses family, couple, and group therapies. Record keeping in supervision and training is covered in Chapter 5.[Page 30]