Record Keeping in Psychotherapy and Counseling provides an essential framework for understanding record keeping within legal, ethical, supervisory, and clinical contexts. Compelling case examples identify dilemmas and strategies in protecting confidentiality. More than a simple reference book, this text introduces the concept of using records as therapeutic tools to strengthen the therapeutic relationship and facilitate clinical supervision. Appendices and an accompanying CD offer sample forms. A reader-friendly style makes this new edition appropriate for undergraduate and graduate students. New material on electronic records, the impact of electronic communication, and practitioners' experiences with implementing the Health Insurance Portability and Accountability Act bring this book up to date. Everyone from students to seasoned practitioners will continue to rely on it for protecting themselves, their patients, and their trainees.
Introduction. Purposes of Clinical Records. Documenting Informed Consent. Characteristics and Contents of Good Records. Confidentiality in an Electronic Age. Exceptions to Confidentiality. Developing Policies and Procedures for Protecting Confidentiality and Managing its Exceptions in an Electronic Era. Boundary Challenges: Impact of Electronic Communication on the Therapeutic Relationship. Retaining and Destroying Inactive Records. Using Patients' Records as Therapeutic Tools. Clinical Supervision Records. Teaching Record Keeping. Psychotherapists and Records in the Legal System. Planning for Interruptions or Closure of Psychotherapy Practices. Epilogue. Appendix A: Sample Client/Patient Information. Appendix B: Sample Treatment Plan Form. Appendix C: Sample Revised Treatment Plan Form. Appendix D: Sample Closing Summary Form. Appendix E: Sample Consent for Treatment of Minor Child Form. Appendix F: Sample Authorization for Release of Information Form. Appendix G: Sample Clinical Supervision Contract. Appendix H: Sample Informed Consent Statement for Mental Health Evaluation in a Personal Injury Case. Appendix I: Sample Letter from a Psychotherapist to a Judge in a Child Custody Case. Appendix J: List of Selected Professional Organizations and their Web Sites. Appendix K: Contents of Accompanying CD.