Record Keeping in Psychotherapy and

Confidentiality is the undisputed cornerstone of the therapeutic process. This text meets the increasing obligation practitioners have to protect their patients while protecting their practices. Drawing on her wealth of experience accumulated over years of practice, supervising and consulting with numerous practitioners on record keeping issues, the author provides valuable and practical tips along with sound general advice. It is a practical and authoritative source that no psychotherapist or clinical supervisor should be without.

Ellen T. Luepker, M.S.W., is a licensed psychologist and clinical social worker in the independent practice of psychotherapy and consultation in St. Paul, Minnesota. She has provided training to mental health professionals nationally and abroad on ethical issues and has given consultation to regulatory boards and attorneys regarding malpractice cases. She was honored by the National Academy of Practice as a Distinguished Practitioner and by the National Association of Social Workers as a Social Work Pioneer for her contributions to professional standards in mental health care

Acknowledgments

vii

Introduction

ix

Purposes of Clinical Records

1

(2)

Documenting Informed Consent

3

(12)

Societal, Legal, and Ethical Bases for Informed Consent

6

(1)

Key Questions to Consider in Documenting Informed Consent

7

(1)

Documentation That Shows Informed Consent

8

(3)

Case Example

11

(3)

Summary

14

(1)

Characteristics and Contents of Good Records

15

(28)

Characteristics

16

(2)

Key Questions to Answer in a Good Record

18

(2)

Essential Contents of a Good Record

20

(18)

What Not to Include

38

(2)

Method of Record Keeping: Does It Matter?

40

(1)

Summary

41

(2)

Confidentiality and Its Exceptions

43

(18)

Definitions of Terms

46

(1)

Parameters of Confidentiality

47

(1)

Threats to Confidentiality

47

(4)

Professional Ethics Codes' Requirements for Protecting Confidentiality

51

(1)

State and Federal Laws That Protect Confidentiality

51

(6)

State and Federal Laws' Exceptions to Confidentiality

57

(2)

Other Considerations

59

(1)

Summary

60

(1)

Policies and Procedures for Protecting Confidentiality

61

(20)

Security Measures

61

(2)

Privacy Measures

63

(7)

Protecting Privacy and Confidentiality of Different Client Populations

70

(7)

Handling Third Party Requests for Records

77

(2)

Summary

79

(2)

Retaining and Destroying Inactive Records

81

(8)

Factors to Consider in Determining How Long to Keep Inactive Records

82

(4)

Policies and Procedures for the Retention/Destruction of Inactive Records

86

(2)

Summary

88

(1)

Using Patients' Records as Therapeutic Tools

89

(14)

History of Clients' Access to Records

90

(1)

How Records Are Used as Therapeutic Tools

91

(11)

Management of Complex, Challenging Situations

102

(1)

Summary

102

(1)

Clinical Supervision Records

103

(8)

Clinical Supervisors' Responsibilities

105

(1)

How Clinical Supervision Records Help Supervisors Fulfill Their Responsibilities

106

(1)

Confidentiality of Supervision Records

106

(1)

Characteristics and Contents of Good Supervision Records

106

(4)

Summary

110

(1)

Teaching Record Keeping

111

(8)

Why Teaching Record Keeping Is Essential

112

(1)

Methods for Teaching Record Keeping

112

(4)

Summary

116

(3)

Psychotherapists and Records in the Legal System

119

(46)

Therapists and the Adversarial Process

120

(5)

Defining One's Role

125

(5)

Handling Attorneys' Requests, Subpoenas, Court Orders, and Search Warrants

130

(5)

After Becoming Involved in a Legal Case, Now What?

135

(9)

Preparing for Deposition or Courtroom Testimony

144

(6)

Testifying

150

(9)

Managing of Clinical Issues During Legal Cases

159

(4)

Summary

163

(2)

Planning for Interruptions or Closures of Psychotherapy Practice

165

(12)

Clinical, Ethical, and Legal Reasons for Having Plans for Records

167

(2)

Procedures that Promote Continuity of Care

169

(6)

Summary

175

(2)

Epilogue

177

(2)

References

179

(54)

Appendices

Appendix A: Excerpts From Mental Health Professions'

185

(4)

Appendix B: Sample Client Information Form

189

(8)

Appendix C: Sample Treatment Plan Form

197

(2)

Appendix D: Sample Revised Treatment Plan Form

199

(2)

Appendix E: Sample Closing Summary Form

201

(2)

Appendix F: Sample Face Sheet and Statement of Understanding and Consent for Treatment and Billing Form

203

(2)

Appendix G: Sample Consent for Treatment of Minor Child Form

205

(2)

Appendix H: Sample Record of Nonroutine Disclosures Form

207

(2)

Appendix I: Sample Authorization for Release of Information Form

209

(2)

Appendix J: Excerpts of Ethical Statements on Confidentiality From Mental Health Professional Organizations

211

(6)

Appendix K: Sample Clinical Supervision Contract

217

(4)

Appendix L: Sample Informed Consent Statement for Mental Health Evaluation in a Personal Injury Case

221

(2)

Appendix M: Sample Letter From a Therapist to a Judge in a Child Custody Case

223

(2)

Appendix N: Organizations to Contact for Further Information About Forensics

225

(2)

Appendix O: Excerpts of Ethical Statements on Record Retention and Destruction From Mental Health Organizations

227

(4)

Appendix P: Additional Excerpts of Ethical Statements on Continuity of Care From Mental Health Organizations

231

(2)

Index

233

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Record Keeping in Psychotherapy and Counseling : Protecting Confidentiality and the Professional Relationship

Summary

Author Biography

Table of Contents

Supplemental Materials