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Behavioral Practice Consulting Solutions
Professional Development
Practice Management Series #3

Topic:   Documentation 

The greatest tool a practitioner has against liability is their documentation regarding all phases of the treatment relationship.  The ability to have documentation regarding the care, permissions, and treatment of a client can make the difference in board hearings or lawsuits.  There is no substitute for accurate and appropriate documentation regarding the professional relationship between counselor and client.  

All therapists should routinely monitor and accurately reflect the services that they provide in comprehensive documentation of a client’s treatment.  A lawyer familiar with mental health issues should review and assist a new therapist (and sometimes a seasoned one) to make sure compliance with applicable laws is met and that there is liability protection regarding common problems encountered in the private practice. 

Here are some basic risk managed documentation policies that should be followed:

            Forms:  From the first interview to the last communication with the client, a practitioner must be sure that legal and ethical practices are maintained.  This means that “Release of Information” forms should be filled out for all applicable parties and should be updated regularly (once a year) as needed.  When there is a lapse in treatment you should have these resigned and updated in a patient’s file to correspond with a renewed therapeutic relationship.  Most important is the “Consent to Treatment” form which is the contract outlining the nature of the professional relationship between counselor and client. 

            Progress Notes:  Progress notes outline the individual sessions of the treatment relationship and are the “meat” of the therapeutic relationship.  As a normal course of ethical practice you will talk about confidentiality of records at the first meeting with a client and then it is up to the practitioners own judgment what is salient to include in the progress note.  There is no absolute rule here.  Some create very detailed and copious notes while others are brief.  These can be hand written or created electronically in a secure computer generated environment.  Either way they need to be secure and available as needed to document the therapeutic relationship. 

            Termination:  Often this step of documentation is left undone.  You want to have a clear policy regarding the termination of a client from your care.  Lapsed clients need to be notified, in writing, of the dissolution of the therapeutic relationship.  Regardless of how therapy ends you will want to appropriately document in the file the termination of the relationship and any details regarding the termination that may be necessary to explain the circumstances of this termination.  The duty-of-care to a client would best be served if this is done in writing, to an authorized mailing address, with a copy kept in the client’s file.  This way you have documented in some fashion your actions regarding this client. 

A final word on this is what an attorney once told me regarding documentation.  He said “if you do not document it, it is as if it never happened.”  As a professional it is your responsibility to substantiate a defense towards claims of malpractice.  Without documentation it becomes a he said/she said problem where the consumer is likely to win due to poor management practices by a professional who did not document the specifics of treatment.

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