Record Keeping in Psychotherapy and Counseling : Protecting Confidentiality and the Professional Relationship

Confidentiality is the undisputed cornerstone of the therapeutic process. This text meets the increasing obligation practitioners have to protect their patients while protecting their practices. Drawing on her wealth of experience accumulated over years of practice, supervising and consulting with numerous practitioners on record keeping issues, the author provides valuable and practical tips along with sound general advice. It is a practical and authoritative source that no psychotherapist or clinical supervisor should be without. Ph.D., author, The Unexpected Legacy of Divorce - Judith Wallerstein This book is a lively, reader-friendly compendium of essential knowledge for every clinician that provides specific advice and examples of clinical records while illuminating a wide spectrum of legal, ethical and complex clinical issues. Purposes of clinical records Documenting informed consent Characteristics and contents of good records Confidentiality and its exceptions Policies and procedures for protecting confidentiality Retaining and destroying inactive records Using patients' records as therapeutic tools Clinical supervision records Teaching record keeping Psychotherapists and records in the legal system Planning for interruptions or closures of psychotherapy practice All mental health organizations have codes of ethics that highlight the paramount importance of protecting patient confidentiality and maintaining the highest professional standards to protect patient welfare. Based on hundreds of interviews with therapists about their concerns, this book provides a framework and guide for addressing issues of confidentiality.