Registered Psychotherapists work in a variety of settings, including agencies, institutions, community service providers, and independent practice. Some may be associated with a group of professionals, including other therapists. In all cases, record-keeping is an important component of good client care.
The clinical record serves as an important reference document and should be complete and accurate. It helps the therapist recall his/her objective observations, and explain choices regarding the plan for, and progress of, therapy. It may also facilitate consultations among therapists or other members of a client’s healthcare team, as well as discussions with the client’s authorized representatives as appropriate.
Clinical records encompass a client profile (personal information provided by the client at the outset of the therapeutic relationship) and corresponding treatment records. They are kept on a client-by-client basis.
When more than one person (e.g. a couple or family) attends therapy, records may be maintained in one file as long as the couple or family attends the sessions in the same combination. However, when the couple or family attend in different combinations, the member should generally keep separate files or sub-files for each individual. For example, if one member of a couple attends for an individual session, a file for the individual session should be maintained separately from the file for the couple.
Similarly, in a group therapy setting, records for the group may be maintained in one file. If, however, a client in the group begins individual therapy with that member, the member creates and maintains a separate file for that client’s individual therapy. If maintaining a hard copy record, each sheet of paper should include the client’s name or unique identifier, date of each entry, and signature of the member. A unique identifier is a code (e.g. a number) that allows the member to identify that client without using the client’s name or other direct personal information. If using unique identifiers, members must securely maintain a key linking each client to their unique identifier.Electronic records should similarly permit each entry to include the client’s name or unique identifier, date and the member’s signature or initials, i.e. evidence that the member in fact
made the record.
The clinical record should also include where relevant:
- the date of every consultation the member receives from another healthcare provider, or the member provides to another healthcare provider, regarding service provided to the client;
- specific information related to any referral made by the member regarding the client;
- notes, forms and other material, regardless of the medium or format (i.e. email, fax, telephone, etc.) in which relevant information has been received from, or provided to, the client or his/her authorized representatives or other professionals involved in the client’s care;
a list of all reports sent or received respecting the client;
- a record of any therapeutic assessment, including assessment method(s) used, outcomes/results, conclusions, problem formulation or other professional opinion regarding client status; and
- a record of conclusion or termination of the therapeutic relationship, including reasons and an explanatory note such as a summary of outcomes attained, a record of referrals, or follow-up recommendations.
Maintaining separate records
RPs may maintain additional notes and documentation, (e.g. progress notes containing particularly sensitive client information), separately from other parts of the clinical record; however, reference to the existence of these notes must be made in the clinical record.
It is important to note that the entire record must be managed in accordance with legal and College requirements. The record, including any separately maintained notes and documentation, must be made available to the client upon request in accordance with PHIPA. In addition, disclosure of the entire record to a third party may be legally compelled, and members should exercise caution when considering what information to include in the record.
The client profile includes the client’s full name, address, telephone numbers, date of birth, and unique identifier (if applicable and/or necessary to distinguish the client from other clients). It also contains relevant information regarding the client’s legally authorized representatives (as applicable and as described in the Health Care Consent Act, 1996), as well as the full name and contact information of any professional who referred the client, along with the reason for the referral. If the client was self-referred, this should be noted as well.
Plan for therapy
The plan for therapy will depend on particular circumstances including the therapeutic approach or model used. The record should minimally indicate the plan or direction that the therapy is intended to take and should log the client’s initial and subsequent consent(s) as necessary. It will also include any reports on tests administered to the client. As the therapeutic relationship continues, changes in the therapy plan will also form part of the record. The initial plan establishes the direction of therapy and helps guide future sessions and evaluate change. The therapy plan may be updated, and will include both subjective and objective information. Subjective information is relevant information provided by the client. Objective information is relevant information observed by the member.
The record includes a notation of all in-session and out-of-session contacts with a client, including any advice or directives given. Examples of out-of-session contacts with clients include letters, emails, texts, telephone calls and videoconferencing.
When a major, unexpected negative outcome occurs, it is important to document the incident in the clinical record as well as any action and/or follow-up undertaken. The documentation should provide a clear record of the incident, which can be used to explain the event and relevant details surrounding it.
There are certain circumstances where federal or provincial laws require the member to advise a person or organization of a serious concern (e.g. child abuse or sexual abuse of a client by a regulated health professional). Members keep a record of all such mandatory reports they make. If the report was not made in writing, members maintain details of the report in their records.
Every entry into the clinical record indicates who made the entry and when. If an amendment to a record is needed, the amendment should indicate what change was made, when, by whom, and why, making sure that the original entry is still legible.
Accessibility of records
Records are prepared and maintained in a timely and systematic manner. Regardless of how the information is structured or stored, it is important that client records are easily accessible.
Where the RP is the custodian of the clinical record, s/he retains the record for at least 10 years from the date of the last interaction with the client, or for 10 years from the client’s 18th birthday, whichever is later. For example, if a child is age 7 at the time of the last interaction, the record would be kept until s/he is 28 years of age.
The Standard: Record-keeping – Clinical Records
Members keep an accurate and complete clinical record for each client. Members provide access to legible client records, when requested to do so by a client, authorized representative or another legal authorization.
Demonstrating the Standard
A member demonstrates compliance with the standard by, for example:
- including a complete client profile in the clinical record;
- including in the clinical record a plan for therapy that is reflective of the modality used;
- ensuring a record of client communications is included in the clinical record;
- including a record of any therapeutic assessments, including methods used, outcomes and results/conclusions;
- including a record of conclusion or termination of the therapeutic relationship, reasons and explanatory notes and a record of referrals and/or follow-up recommendations in the clinical record;
- completing incident and mandatory reports as warranted;
- ensuring the clinical record is accessible, maintained in a timely manner, legible, written in plain language, and written in English or French; and ensuring that records are accurate, and that amendments show changes and original entries;
- ensuring that, if progress notes are maintained separately from the main clinical record, the clinical record includes a notation to that effect.
Professional Misconduct Regulation, provisions 25, 26, 27
Note: College publications containing practice standards, guidelines or directives should be considered by all members in the care of their clients and in the practice of the profession. College publications are developed in consultation with the profession and describe current professional expectations. It is important to note that these College publications may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.