keeping medical records

If you are a California mental health professional such as a licensed marital and family therapist (LMFT), licensed psychological clinical counselor (LPCC) or licensed clinical social worker (LCSW), are you keeping the necessary level of detail in your patient records to protect your professional license?

Consider the following two vignettes:

1) Ima Counselor is a therapist who has been in practice for 35 years. Today she is waiting in her office for her bimonthly appointment with her long-term client, Ura Client. Ura is already fifteen minutes late which is unusual for her. Ima tries to recall their last session to understand if there could be a clinical reason for Ura’s lateness. Ima’s caseload has been so busy in the last two weeks that she can’t remember the specifics of their last session and only remembers Ura continuing to feel sad about her ongoing marital issues. Ima does not keep psychotherapy records so does not have notes to review. Ima cares deeply for her clients and chooses not to chart because she feels that keeping notes of her clients’ innermost thoughts and experiences betrays the sanctity of therapy. Ima does not believe therapists should be subjected to the medical model. Finally, Ima receives a text from Ura. The text says that Ura’s husband just filed for divorce, and Ura is standing on a bridge unwilling to live without him. Ima recently took a continuing education course about texting and HIPAA compliance, so Ima chooses to call Ura immediately instead of texting. Ura does not answer and commits suicide. Ima is later notified that her client’s family has filed a malpractice/wrongful death lawsuit against Ima claiming that Ima failed to conduct a proper suicide risk assessment and failed to prevent Ura’s suicide. Ima’s state licensing board begins disciplinary proceedings, which will include requesting Ima’s psychotherapy records, threatening Ima’s career and reputation. Ima has no records and, in addition to feeling deeply upset about her client’s suicide, is worried about her professional liability.

2) Ima Counselor is a psychotherapist who has been in practice for 35 years. Today she is waiting in her office for her bimonthly appointment with her long-term client, Ura Client. Ura is already fifteen minutes late which is unusual for her. Ima tries to recall their last session to understand if there could be a clinical reason for Ura’s lateness. Ima’s caseload has been so busy in the last two weeks that she can’t remember the specifics of their last session and only remembers Ura continuing to feel sad about her ongoing marital issues. Ima keeps detailed psychotherapy notes for all of her clients. After each client session, Ima charts what her clients say and how she responds therapeutically, updating the treatment plan as necessary. Ima reviews Ura’s chart for signs of a possible rift in the therapeutic relationship or any safety concerns but sees neither. Ima then receives a text from Ura. The text says that Ura’s husband just filed for divorce, and Ura is standing on a bridge unwilling to live without him. Ima recently took a continuing education course about texting and HIPAA compliance, so Ima decides to call Ura immediately instead of texting. Ura does not answer and commits suicide. Ima is later notified that her client’s family has filed a malpractice/wrongful death lawsuit against Ima claiming that Ima failed to conduct a proper suicide risk assessment and failed to prevent Ura’s suicide. Ima’s state licensing board begins disciplinary proceedings, which will include requesting Ima’s psychotherapy records, threatening Ima’s career and reputation. Ima keeps detailed charts and, although deeply upset by her client’s suicide and shaken by being sued, is confident that her psychotherapy notes will help to protect her professionally.

The above examples underline the importance of establishing proper record-keeping practices in a mental health practice. Keeping psychotherapy records protects both client and practitioner, yet some practitioners still choose not to keep client records. Legal requirements and ethical standards must be considered in addition to state licensing board guidelines.

Keeping psychotherapy records benefits the mental health practitioner by providing:

• Proof of the standard of care such as legal, ethical, HIPAA, and state licensing requirements.

• Proof of competent care by including treatment plans, office policies, client progress notes, consent forms, and case consultation/referral notes.

• Reminders to the practitioner of a client’s treatment details.

• Proof of continuity of care to the client when a client is referred to another professional, when a considerable period of time elapses between client sessions, or if a client is transferred to a different therapist for either clinical reasons or due to the unanticipated death/illness of the original therapist.

• Protection in the event of legal or ethical proceedings between therapist and client. A therapist’s psychotherapy records are an important factor for a licensing board when deciding to pursue a client’s complaint.

Maintaining psychotherapy records benefits the client by providing:

• Treatment details for third-party reimbursement.

• Reminders to the practitioner of a client’s life story.

• Continuity of care to the client when a client is referred to another professional, when a considerable period of time elapses between client sessions, or if a client is transferred to a different therapist for either clinical reasons or due to the unanticipated death/illness of the original therapist.

• Evidence in the event of legal proceedings between the client and a third party.

Keeping psychotherapy records is regulated by federal and state laws in addition to professional licensing boards and benefits both therapist and client.

So why do some mental health practitioners choose either not to chart or to keep minimal records?

Some therapists reason that there is not enough time between client sessions to chart in addition to tending one’s personal needs such as checking voicemail, using the restroom, or eating. Others feel there is nothing new to add to a client’s chart after every session or are intimidated by terms such as HIPAA compliance. Some may believe that keeping psychotherapy records could violate a client’s confidentiality if records are sought by third parties, such as insurers or divorce attorneys. Others are overwhelmed when deciding between the legal and ethical considerations of paper vs. digital records. Some therapists erroneously assume that disciplinary action will never occur to them and, if it ever did, mistakenly believe that psychotherapy records could be cobbled together at that time.

It is important to remember that a licensing board considers the therapist’s psychotherapy records when deciding to pursue disciplinary action after receiving a client’s complaint. If it’s not in the record, it didn’t happen. Mental health practitioners must understand the laws, ethical standards, and state licensing board requirements pertaining to record keeping.

If you are a mental health professional facing disciplinary action, it is imperative to enlist the assistance of an experienced licensing attorney at the earliest stage of the disciplinary process. The Law Offices of Lucy S. McAllister are here to help. We understand the unique legal complexities facing mental health practitioners. We have the knowledge and experience to craft a comprehensive strategy and are dedicated to navigating your specific case through the disciplinary process to best defend your professional interests.

The Law Offices of Lucy S. McAllister have successfully represented a wide range of California licensed professionals including mental health practitioners, accountants, engineers, and medical professionals such as nurses, physicians, chiropractors, dentists, and veterinarians. We are experienced in handling all types of licensing issues. Let us help you protect your professional license, your reputation, and your livelihood.

For additional information or to schedule a consultation on a professional licensing issue, please contact us today at (877) 280-9944.

Disclaimer: This article is intended for educational purposes only and does not constitute specific legal advice or outcome guarantees. This article does not establish an attorney-client relationship between you and the blog/website publisher and should not be used as a substitute for legal advice from a licensed professional attorney.

For Additional Information

American Psychological Association – Record Keeping Guidelines

California Board of Behavioral Sciences – Complaint Information

California Association of Marriage and Family Therapists – On Writing Progress Notes

California Board of Psychology – Forms and Publications