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Record Keeping in Psychotherapy & Counseling

Resources

This resource page is part of an Online Course
Record Keeping in Psychotherapy & Counseling: Ethical, Legal, and Clinical Issues

CE Credits for Psychologists. CE Credits (CEUs) for LMFTs, Social Workers, Counselors and Nurses.
CE Approvals by BBS-CA, ASWB, NBCC, NAADAC, CA-BRN & more.
Zur Institute is approved by the American Psychological Association to sponsor continuing education for psychologists. Zur Institute maintains responsibility for this program and its content.

 

 

General Resources

 

Professional Organizations Guidelines

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Record Retention Requirements

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Clients' Requests to Review and/or Amend Their Records

  • CA: Patients' right to access their records CA Health and Safety Code ยง 123100-123149.5: http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=123001-124000&file=123100-123149.5:
    123110. (a) Notwithstanding Section 5328 of the Welfare and Institutions Code, and except as provided in Sections 123115 and 123120, any adult patient of a health care provider, any minor patient authorized by law to consent to medical treatment, and any patient representative shall be entitled to inspect patient records upon presenting to the health care provider a written request for those records and upon payment of reasonable clerical costs incurred in locating and making the records available.

 

Correcting and Altering Clinical Records

 

Additional References

  • Allan, A., & Allan, M. M. (2016). Psychologists' collection and management of clients' information: An ethico-legal perspective. Psychiatry, Psychology and Law, 23(6), 826-841. http://dx.doi.org/10.1080/13218719.2016.1160745
  • Barnett, J. E., & Molzon, C. H. (2014). Clinical supervision of psychotherapy: Essential ethics issues for supervisors and supervisees. Journal of Clinical Psychology, 70(11), 1051-1061. DOI:10.1002/jclp.22126
  • Bond, T., & Mitchels, B. (2015). Confidentiality & record keeping in counselling & psychotherapy (2nd Ed.). Los Angeles, CA: SAGE.
  • Bradford, L., & Stevens, B. (2013). What's in the file? Opening the drawer on clinical record keeping in psychology. Australian Psychologist, 48(3), 178-187. DOI:10.1111/j.1742-9544.2012.00080.x
  • Bradshaw, K. M., Donohue, B., & Wilks, C. (2014). A review of quality assurance methods to assist professional record keeping: Implications for providers of interpersonal violence treatment. Aggression and Violent Behavior, 19(3), 242-250. https://doi.org/10.1016/j.avb.2014.04.010
  • Christie, C. D., Bemister, T. B., & Dobson, K. S. (2015). Record-informing and note-taking: A continuation of the debate about their impact on client perceptions. Canadian Psychology/Psychologie canadienne, 56(1), 118-122. http://dx.doi.org/10.1037/a0037860
  • DeLettre, J. L., & Sobell, L. C. (2010). Keeping psychotherapy notes separate from the patient record. Clinical Psychology & Psychotherapy, 17(2), 160-163. DOI:10.1002/cpp.654
  • DiCarlo, R., & Garcia, Y. E. (2016). Electronic record keeping and psychotherapy alliance: The role of concurrent collaborative documentation. In S. Tettegah, & Y. E. Garcia (Eds.). Emotions, Technology, and Health (pp. 63-82). San Diego, CA: Elsevier.
  • Drogin, E. Y., & Armontrout, J. A. (2017). Recordkeeping in private practice. In S. Walfish, J. E. Barnett, & J. Zimmerman (Eds.), Handbook of private practice: Keys to success for mental health practitioners (pp. 66-77). New York, NY: Oxford University Press.
  • Elhai, J. D., & Frueh, B. C. (2016). Security of electronic mental health communication and record-keeping in the digital age. The Journal of Clinical Psychiatry, 77(2), 262-268. DOI: 10.4088/JCP.14r09506
  • Fors, M., & McWilliams, N. (2016). Collaborative reading of medical records in psychotherapy: A feminist psychoanalytic proposal about narrative and empowerment. Psychoanalytic Psychology, 33(1), 35-57. http://dx.doi.org/10.1037/pap0000019
  • Larrison, C. R., Xiang, X., Gustafson, M., Lardiere, M. R., & Jordan, N. (2017). Implementation of electronic health records among community mental health agencies. The Journal of Behavioral Health Services & Research, 1-10. doi:10.1007/s11414-017-9556-9
  • Lo, C. L., & Wadsworth, J. (2014). The impact of novice counselors' note-taking behavior on recall and judgment. Rehabilitation Research, Policy, and Education, 28(3), 169-182. DOI:https://doi.org/10.1891/2168-6653.28.3.169
  • Pope, K. S. (2015). Record-keeping controversies. Canadian Psychology/psychologie canadienne, 56(3), 348-356. http://dx.doi.org/10.1037/cap0000021
  • Purves, D. (2015). The ethics and responsibilities of record keeping and note taking. In R. Tribe, & J. Morrissey (Eds.). Handbook of professional and ethical practice for psychologists, counsellors and psychotherapists (2nd Ed. pp. 82-92). New York, NY: Routledge.
  • Routledge, C. (2015). Ethical standards in clinical psychology: Maintaining integrity, record keeping and confidentiality. Journal of Applied Psychology and Social Science, 1(1), 15-27. Retrieved from: http://194.81.189.19/ojs/index.php/apass/article/view/210
  • Steinfeld, B. I., & Keyes, J. A. (2011). Electronic medical records in a multidisciplinary health care setting: A clinical perspective. Professional Psychology: Research and Practice, 42(6), 426-432. http://dx.doi.org/10.1037/a0025674
  • Tansel, A. U. (2013). Innovation through patient health records. Procedia-Social and Behavioral Sciences, 75, 183-188. https://doi.org/10.1016/j.sbspro.2013.04.021
  • Wiarda, N. R., McMinn, M. R., Peterson, M. A., & Gregor, J. A. (2014). Use of technology for note taking and therapeutic alliance. Psychotherapy, 51(3), 443-446. http://dx.doi.org/10.1037/a0035075

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