Guidelines for Client Records

Guidelines on Confidentiality and Record Keeping
Rigorous respect for issues of confidentiality is fundamental to the ethical practice of counselling and psychotherapy. Practitioners will clarify and explain the nature and extent of confidentiality from the start of the contract. All circumstances in which confidentiality may be breached will be identified.

Client records must be held securely at all times. The nature and purpose of records kept and the client’s rights of access will be made clear at the outset of the contract. Practitioners will make provision for appropriate access to records and appropriate notification of clients in the event of their own death or incapacity.

Agreements about confidentiality will continue after a client’s death unless legal or ethical considerations demand otherwise.

Confidentiality in the legal process
It is a fundamental responsibility of the practitioner to be aware of the specific legal implications of their work, including the general legal requirements concerning the giving and withholding of information, and the obligation to seek professional support and guidance when necessary.

The practitioner will establish channels for discussing legal issues with appropriately qualified people, in advance of the specific need

Maintenance of Records
Records are maintained for a variety of reasons, the most important of which is the benefit of the client. Records allow a practitioner to document and review the delivery of counselling and psychotherapy services. The nature and extent of the record will vary depending upon the type and purpose of services. Records can provide a history and current status in the event that a user seeks services from another mental health professional.

Maintenance of appropriate records may also be relevant for a variety of other institutional, financial, and legal purposes.

In addition, well documented records may help protect counsellors and psychotherapists from professional liability, if they become the subject of legal or ethical proceedings. In these circumstances, the principal issue will be the professional action of the practitioner, as reflected in part by the records.

At times, there may be conflicts between the federal, state or local laws governing record keeping, the requirements of institutional rules, and these guidelines. In these circumstances, counsellors and psychotherapists should bear in mind their obligations to conform to applicable law.

Content of Records
Records include any information (including information stored in a computer) that may be used to document the nature, delivery, progress, or results of counselling and psychotherapy services. Records can be reviewed and duplicated.

Records of these services minimally include (a) identifying data, (b) dates of services, (c) types of services, (d) fees, (e) any assessment, plan for intervention, consultation, summary reports, and/or testing reports and supporting data as may be appropriate, and (f) any release of information obtained.

As may be required by their jurisdiction and circumstances, practitioners maintain to a reasonable degree accurate, current, and pertinent records of services. The detail is sufficient to permit planning for continuity in the event that another practitioner takes over delivery of services, including, in the event of death, disability, and retirement. In addition, practitioners maintain records in sufficient detail for regulatory and administrative review of service delivery.

Records kept beyond the minimum requirements are a matter of professional judgment for the practitioner. The practitioner takes into account the nature of the services, the source of the information recorded, the intended use of the records, and his or her professional obligation.

Practitioners make reasonable efforts to protect against the misuse of records. They take into account the anticipated use by the intended or anticipated recipients when preparing records. Practitioners adequately identify impressions and tentative conclusions as such.

Construction and Control of Records
Practitioners maintain a system that protects the confidentiality of records. They must take reasonable steps to establish and maintain the confidentiality of information arising from their own delivery of services, or the services provided by others working under their supervision.

Practitioners have ultimate responsibility for the content of their records and the records of those under their supervision. Where appropriate, this requires that the practitioner oversee the design and implementation of record keeping procedures, and monitor their observance.

Practitioners maintain control over their clients' records, taking into account the policies of the institutions in which they practice. In situations where practitioners have control over their clients' records and where circumstances change such that it is no longer feasible to maintain control over such records, practitioners seek to make appropriate arrangements for transfer.
Records are organised in a manner that facilitates their use by the practitioner and other authorised persons. Practitioners strive to assure that record entries are legible. Records are to be completed in a timely manner.

Records may be maintained in a variety of media, so long as their utility, confidentiality and durability are assured.

Retention of Records
The practitioner is aware of relevant federal, state and local laws and regulations governing records retention. Such laws and regulations supersede the requirements of these guidelines. In the absence of such laws and regulations, complete records are maintained for a minimum of 3 years after the last contact with the client. Records, or a summary, are then maintained for an additional 12 years before disposal. If the client is a minor, the record period is extended until 3 years after the age of majority.

All records, active and inactive, are maintained safely, with properly limited access, and from which timely retrieval is possible.

Outdated Records
Practitioners are attentive to situations in which record information has become outdated, and may therefore be invalid, particularly in circumstances where disclosure might cause adverse effects. Practitioners ensure that when disclosing such information that its outdated nature and limited utility are noted using professional judgment and complying with applicable law.

When records are to be disposed of, this is done in an appropriate manner that ensures nondisclosure (or preserves confidentiality).

Disclosure of Record Keeping Procedures
When appropriate, practitioners may inform their clients of the nature and extent of their record keeping procedures. This information includes a statement on the limitations of the confidentiality of the records.

Practitioners may charge a reasonable fee for review and reproduction of records. Practitioners do not withhold records that are needed for valid healthcare purposes solely because the client has not paid for prior services.