… Therapists and counselors should recognize that good record keeping practices will often serve to protect both the practitioner and the patient/client. The records may be used in litigation to attempt to prove or support the patient’s case, and a failure to keep adequate records may prove costly to the patient. Records are also important when the therapist’s professional conduct is being questioned. Therapists who keep good records are generally better able to defend themselves if accused of wrongdoing. Some state laws specify or mandate the content of clinical records, while other states essentially leave content largely to the discretion of the practitioner.
One aspect of record keeping, too often neglected, involves the obtaining of records concerning treatment of the patient by other practitioners or health facilities occurring prior to the time the therapist or counselor sees the patient. How often do you seek prior records of hospitalization? What about treatment records from other therapists – do you routinely or ever request them? Therapists and counselors should not forget to obtain prior treatment records in those cases that they deem it clinically necessary or appropriate. Remember, the failure to obtain prior treatment records can lead to liability. A judge or jury may find that the failure to obtain prior records in a particular case amounted to negligence.