Secure and appropriate record-keeping is essential for good client care. The client record enables the member to keep track of what was done and what was considered by the therapist. It may also provide information for other therapists and professionals who may provide services to the same client. It enables the member to track progress, note changes in a client’s condition, and make adjustments to the therapy plan if needed. Records also allow a member to explain and defend what was done, if and when required.
Records are important for both clinical and operational aspects of practice.
Members should keep the following types of records which are all part of the client record:
- clinical records;
- appointment records; and
- financial records.
When preparing and maintaining records, Registered Psychotherapists are subject to the Personal Health Information Protection Act, 2004. PHIPA governs therapists’ use of personal health information, including its collection, use, disclosure and access.
A health information custodian is the person or organization responsible for maintaining health records. If practising alone, the member is the health information custodian of his/her clients’ records. If an RP is working in an employment situation, s/he is expected to follow the record management practices of his/her employer. This assumes that the employer’s record management practices comply with PHIPA. If this is not the case, the member must ensure that his/her clinical records comply with PHIPA. The organization may have an information officer to monitor compliance with PHIPA.
Under PHIPA, clients have a right to access their own health records and to correct errors in them. While records are not written primarily for clients to read, they should be legible and intelligible to readers, including the client, insofar as is reasonably possible.
Also, while the College acknowledges that therapeutic services may be provided in any number of languages (including sign language), the written record – for the purpose of record-keeping – is to be maintained in one of Canada’s two official languages, English or French.
Clients not satisfied with the way their records have been maintained or shared have a right to make a complaint. Members should inform clients of their right to complain to the College and/or the Information and Privacy Commissioner. In addition, clients have the right to require that inaccuracies in their health record be corrected.