7.7 Record Keeping
Ethical and legal codes dictate the need for accurate and thorough records of counseling sessions; General ACA and NAADAC codes on record keeping are included below (ACA, 2014; NAADAC, 2021).
“Counselors create and maintain records and documentation necessary for rendering professional services” (ACA, 2014, Standard B.6.a.)
“Addiction professionals, during informed consent, shall disclose the legal and ethical limits of confidentiality and shall disclose the legal exceptions to confidentiality. Confidentiality and limitations to confidentiality shall be reviewed as needed during the counseling relationship. Providers shall review with each client all circumstances where confidential information may be requested and where disclosure of confidential information may be legally required” (NAADAC, 2021, Standard II-2).
Record keeping is a written synopsis of objective discourse in the counseling session. Clinical judgment in the note is marked as such. In general, clinical records outline the need for services, the trajectory of counseling work, treatment plans, and, eventually, termination (Drogin, 2010). Because counselors provide a range of services, their record-keeping reflects these nuances. For example, notes for crises, group therapy, family therapy, and individual therapy will differ in context, scope, and length. In determining what to include, counselors consider legal needs, ethics, agency requirements, insurance coverage, the context of the relationship, and treatment goals (Drogin, 2010). Overall, counselors are ethically responsible for creating, maintaining, storing, and disseminating client’s records in ways that promote client welfare, thereby protecting their right to confidentiality (American Psychological Association [APA], 2003). Keeping accurate and reliable records is also vital for referrals to other professionals or changing levels of care (Drogin, 2010). For research professionals, records are thorough so that another person can accurately replicate the study protocol, which validates the research design and analysis and ensures compliance with institution standards and legal statutes (APA, 2003).
What is Included in Client Records?
The American Psychiatric Association (APA) urges counselors to be objective and concise in note-taking (Drogin, 2010). They share only what is necessary to justify a client’s participation in services, billing, and momentum in treatment. They also consider the importance of privacy and confidentiality and include succinct information to meet the agency’s documentation goals and managed care agreements.
The APA suggests including the following in client records (Drogin, 2010):
General file information, which includes
Client’s name, contact information, emergency contact information
The fee agreement for counseling, billing information
Guardianship or conservator status (if applicable)
Releases of information
The client’s reasoning for seeking services and historical data (i.e., psychological testing reports, records, etc.) related to the functioning
Informed consent practices
Documentation of significant contact
Date, time, and duration of clinical contact, type of service provided
Overarching themes or interventions provided during the session
Counselor’s theoretical orientation, style of intervention
Mental status exam and observed behaviors from the session
Counselor utilizes person-centered, non-judgmental language
Miscellaneous information
This is optional but could include assessment results, screening tool results, other case information, collateral information (with ROI), correspondence with other professionals, medical records/ physical health updates, and materials provided by the client, including journal articles, art, poetry, logs, etc.
Counselor Responsibilities Regarding Record-Keeping
Ethical codes and legal statutes govern record-keeping practices; counselors uphold these. The ACA (2014) highlights this practice specifically:
“Counselors ensure that records and documentation kept in any medium are secure and that only authorized persons have access to them” (Standard B.6.b.).
Purposes of record keeping include promoting treatment goals and therapeutic momentum, justifying insurance coverage, and protecting clients and counselors from potential disputes around clinical care, fee arrangements, treatment outcomes, etc. (Drogin, 2010). With client permission, records can be shared with other professionals to foster case consultation and promote client care (Drogin, 2010). When they coordinate care with other professionals, counselors are careful not to take client records out of context, and use discernment in integrating information gathered in those meetings with data gleaned during the therapeutic process (Drogin, 2010). Additionally, as ethical concerns arise in their work with clients, counselors document thoughtful and thorough ethical decision-making processes to uphold client beneficence and non-maleficence.
Counselors protect client records from “unauthorized access, damage or premature destruction” to maintain alignment with adequate confidentiality (Drogin, 2010). Per APA guidelines, counselors must maintain clinical records for at least 3 years after the date of last contact with a former client and store them safely (APA, 2003). It is recommended that counselors consult state statutes for legal discrepancies in the timing and adhere to the more stringent guidelines between them. Notes can be stored in one of two forms- physical, paper copies, or electronic records. See the table below for considerations regarding each form.
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Paper Records |
Electronic Records |
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This likely includes the counselor’s personal notes taken during a session, faxed paperwork, etc. The purpose is generally to promote therapeutic work, but this can exist for a variety of reasons. |
This typically includes formal records stored in electronic health records to guide patient care, billing, and agency operations. |
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Keep in a locked file cabinet and within a locked office/ storage space to ensure client privacy. |
There is often a legal duty to keep electronic files encrypted; Refer to state statutes to determine legal needs in your jurisdiction. |
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What happens when the counselor is out of the room/ office? Can other people access it? |
Use adequate, smart passwords and change them every 3 months or more often. |
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Remember that locked facilities are unlocked during business hours. Sometimes, offices are shared spaces, or maintenance people can access them during off hours. How are physical records kept safe in these instances? |
Consider what would happen in the event of a theft of a device (mobile phone or laptop) or a data hacking incident. How can client data be safeguarded if devices are stolen? Breaches like this can have legal and ethical consequences. |
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Store data on backup devices or drives. Consider the safety of those places, and keep physical drives or discs locked up for safety |
Safety considerations for different types of record storage to protect client privacy (Fisher, 2010).
Case Study: Documentation Oversight in Counseling
Jon, a 28-year-old client, is in therapy with Kendra for issues related to depression and stress management. Over several months, Kendra keeps detailed notes on Jon’s progress, treatment plans, and session content.
During a routine audit of client records, it is discovered that Kendra’s documentation for Jon’s sessions is inconsistent. Some notes are missing, and others lack specific details about the interventions used and Jon’s responses. Additionally, the treatment plan was not updated to reflect recent changes in Jon’s goals and progress. Jon requests a copy of his records for his own review, but Kendra’s incomplete documentation makes it difficult for him to understand his treatment history and current plan. Jon expresses concern about the accuracy of the records and the effectiveness of his treatment.
Jon feels uncertain about the progress he’s made and whether the treatment is being effectively managed. He becomes frustrated with the lack of clarity in his records. Kendra faces scrutiny from the clinic’s review board for failing to maintain accurate and comprehensive documentation. This oversight raises questions about the quality of care provided and could impact Kendra’s professional standing.
Discussion Questions
- Why is accurate and thorough documentation crucial in counseling practice?
- What steps can counselors take to ensure their documentation is consistent and complete?
- How can incomplete or inaccurate documentation impact the therapeutic process and client trust?
Key Takeaways
- Accurate and thorough record-keeping ensures continuity of care, supports treatment goals, and protects both clients and counselors from disputes.
- Documentation should include client information, session details, treatment plans, and other relevant data, using objective and concise language.
- Counselors must secure client records, whether in paper or electronic form, to protect confidentiality and meet ethical and legal requirements.
- Maintaining comprehensive records facilitates collaboration with other professionals and supports ethical decision-making processes.
- Incomplete or inconsistent documentation can undermine client trust, impact the therapeutic process, and result in professional and legal repercussions.