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.
Chapter 3: Contents of a Good Record
Contents of a Good Record
We have pointed out the importance of keeping records in psychotherapy and that a record can benefit both the therapist and the client. Do you know the criteria for a good record? When are you recording too many details or not enough? In this chapter, we describe in detail (a) what not to keep in your files, (b) what we believe are the minimum criteria required for a client's file to meet ethical and legal standards, and (c) the maximum criteria that would constitute a good record and therefore protect both yourself and your clients. Keep in mind that financial records are better kept separate from treatment records.
Material Not to Include
Certain materials that you will receive ...