Alexandra M. Price, PsyD, didn't receive much training about record-keeping as a graduate student. Now working at Madison State Hospital in Madison, Ind., she says her on-the-job training has been a baptism by fire. Today she tries to live by a single record-keeping rule: "If people are reading your notes and asking you what you meant, you aren't writing enough; if you are getting cramps in your wrist, you are writing too much!"
Like Price, many graduate students don't get in-depth training in record-keeping until they're in internships or their first jobs. But good record-keeping is a crucial part of practice, experts say. And experienced practitioners and others can offer plenty of advice about how to create records, safeguard them and destroy them when they're no longer needed.
Gilbert H. Newman, PhD, post-president of the California Psychological Association and director of clinical training at the Wright Institute in Berkeley, Calif., admits that record-keeping isn't the sexiest topic.
"Whenever I talk to people about records, I remind myself of the Dilbert cartoon where a boring bureaucrat is speaking and everyone listening to him is turning into brick walls," says Newman, who gives record-keeping workshops for practitioners. "Record-keeping is not the sort of thing that a lot of people are interested in talking about."
Dull or not, say Newman and others, good record-keeping is vital. Records benefit clients by documenting their history, their current condition and the services they've received, says Newman. Records also help practitioners plan treatment, monitor whether that treatment is working and protect themselves from liability in cases of legal or ethical proceedings. Plus, the federal government, states and third-party payers have their own rules about record-keeping.
Basic records, often called progress notes, cover the who, what and when of treatment. These records, says Newman, should include such information as dates and types of services, assessments, intervention plans, consultations, testing reports, releases of infor-mation, consent forms and any supporting data.
There should be enough detail to avoid misunderstandings if your records are subpoenaed or to guide another clinician if you're no longer able to continue treatment for whatever reason, says Newman. Back up assertions with details, he adds. Instead of simply saying a patient is depressed, for instance, note that he was trembling, crying and said he was sleeping poorly.
Be sure to avoid problematic language that might be misleading or excessive, adds Melba Vasquez, PhD, an independent practitioner in Austin, Texas, and co-author of "How to Survive and Thrive as a Therapist: Information, Ideas and Resources for Psychologists in Practice" (APA, 2005).
Say a woman comes in to deal with the trauma of being raped, says Vasquez. It would be appropriate to note crying, tension and the like. "On the other hand," she says, "an entry that said the client was being dramatic about what happened, dressed seductively and so on would be inappropriate."
Also document any unusual struggles or dilemmas the client experiences during the therapeutic process and how you resolved them, recommends Vasquez. Doing so, she says, can help protect practitioners if the client later makes a complaint.
In addition to these progress notes, psychologists can keep psychotherapy or process notes for their own use.
"These notes include a little bit more detail that some therapists like to include, perhaps information they consider relevant to hypotheses or analyses about behavior change," says Vasquez. As long as they're kept physically separate from progress records, the federal Health Insurance Portability and Accountability Act (HIPAA) gives such notes special protection. In most situations, psychologists can't release psycho-therapy notes unless the patient signs a detailed authorization form specifically authorizing their release. State practice laws regarding note-keeping requirements should also be considered, she says.
For those who aren't solo practitioners, say Vasquez and others, it's important to learn the record-keeping culture of your workplace.
Jessica R. Gurley, a fourth-year clinical psychology student at Sam Houston State University in Huntsville, Texas, agrees. "Each practicum site has a different way of keeping records," she says. What all sites should have in common is an emphasis on complying with HIPAA, which protects the privacy of personal health information.
Even if your practicum or internship site doesn't cover HIPAA and other rules, say experts, you're still responsible for protecting patients' privacy. And when it comes to protecting records from prying eyes, simply keeping files under lock and key may not be enough.
Every psychologist and trainee should be aware of HIPAA rules as well as other federal and state laws governing record-keeping practices, says Mary A. Connell, EdD, chair of APA's Committee on Professional Practice and Standards and a private practitioner in Fort Worth, Texas. The committee is revising APA's Record Keeping Guidelines to take into account HIPAA and other changes since the guidelines were first released in 1993. The revised guidelines are expected to be approved by APA's Council of Representatives in 2007.
For one thing, HIPAA doesn't always have the last word. "If a state law provides more protection for the client," Connell explains, "then it likely takes precedence over the HIPAA Privacy Rule."
Sally R. Cameron, executive director of the North Carolina Psychological Association, has given workshops around the state to help practitioners and students learn how to comply with HIPAA rules.
HIPAA's Privacy Rule lays out to whom and under what circumstances psychologists can disclose patients' records, Cameron explains. HIPAA's Security Rule requires psychologists to take steps to guard against unintended disclosures of or the destruction of electronic information. The APA Practice Organization's portal, www.apapractice.org, which is free to practice-oriented graduate students and licensed practitioners who pay the APA Practice Organization Assessment, offers primers and other tools that can help practitioners comply with both rules.
Complying with the security rule includes doing whatever you need to do to ensure that only those who are supposed to see the records stored on your desktop, laptop or handheld computer actually see them, says Cameron, noting the importance of strong passwords, firewalls and virus protection.
"If you're keeping records on a laptop and you take that laptop home, you have got to have a firewall so that your kids playing games on your computer can't get into the protected information," she says.
In addition to analyzing security risks, says Cameron, practitioners should also incorporate into their records specific information about how they've safeguarded those records. "You need to document every step of what you've done," emphasizes Cameron. Of course, she adds, psychologists and trainees working in institutional settings should follow the directions of their HIPAA compliance officer.
DISPOSING OF RECORDS
How long must practitioners keep records of patients they no longer see?
State laws vary, says Connell, noting that the drafters of the revised APA guidelines initially suggested keeping records for seven years after last contact for adults and seven years after minors become adults (check APA's Web site for the final recommendation). Vasquez suggests determining the longest period required by any of the entities with authority over your practice and keeping records that long. Texan law, she points out, requires records to be kept 10 years after the last contact and 10 years after the age of majority for minors. Outdated paper records should be shredded, she says.
Be extra careful when deleting electronic records, warns Cameron.
"Don't assume that just because you've erased something from your hard drive it's erased," she says. "It's embedded in there." Before you donate your old computer or toss it in the trash, she suggests, have an information technology expert make sure your hard drive is clean.
It's also important to make arrangements for safeguarding your records should you leave your practice, become too disabled to work or die, says Vasquez. Practitioners should make legal arrangements to transfer responsibility for the records to another professional.
Rebecca A. Clay is a writer in Washington, D.C.
www.apapractice.org. The APA Practice Organization’s portal offers information on HIPAA and other record-keeping issues to practice-oriented graduate student members of APAGS and to licensed practitioners who pay the APA Practice Organization Practice Assessment.
Link to APA Record Keeping Guidelines.
www.microsoft.com/athome/security/privacy/password_checker.mspx.Check the strength of your password and find out how to make it more secure.
Behnke, S. (2005, February). Record-keeping under the new Ethics Code. Monitor on Psychology, 36, 72–73.
Daw Holloway, J. (2003, February). Professional will: A responsible thing to do. Monitor on Psychology, 34, 32.
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