Understanding what should be included in a client’s medical record is essential for mental health practitioners, especially with increasing scrutiny on transparency and compliance. Proper documentation directly impacts continuity and quality of care, aligning with client rights and regulatory standards. Here’s a breakdown of what should be included, what may be excluded, and strategies for creating accurate, thorough records.
What Constitutes a Client Record?
A client record isn’t limited to clinical notes; it encompasses all forms of communication and documentation relevant to a client’s care. This includes intake questionnaires, email, text messages, voicemails, and even logistical details if they inform the client’s healthcare. Practitioners often assume that only clinical information needs recording, but HIPAA and state laws mandate that any content related to healthcare must be documented.
In particular:
- Intake and assessment information: From the client’s initial questionnaire to ongoing assessments, all material that could inform treatment should be documented.
- Communications: Emails, text messages, and voicemail summaries—whether clinically relevant or purely logistical—should be part of the record if they provide context for diagnosis, assessment, or interventions.
- Clinical notes: Progress notes, detailing treatment goals, outcomes, and client behavior patterns, are fundamental.
The inclusion of these diverse types of information in records provides essential context for diagnosis and continuity of care, ensuring a holistic understanding of the client’s journey.
Progress Notes vs. Psychotherapy Notes
There’s a crucial distinction between progress notes and psychotherapy notes. Under HIPAA, psychotherapy notes are generally exempt from release as part of a medical record. They are intended solely for the provider’s personal reflection on therapeutic processes, but they must not overlap with content found in the client’s primary medical record, such as assessment or intervention details. Some states, however, may not protect psychotherapy notes under this provision, making it essential to verify state-specific regulations.
Practitioners should:
- Keep psychotherapy notes distinct from the medical record if they are used, ensuring they don’t contain elements that HIPAA and state laws require in a client’s record.
- Document with awareness of client access, especially as recent regulations (such as the 21st Century Cures Act) emphasize clients’ rights to review their healthcare records, fostering transparency.
Adapting Documentation Practices
Mental health documentation has traditionally been seen as confidential, solely for the clinician’s reference. This perspective has evolved with the Open Notes Rule, highlighting the client’s right to view records as part of their healthcare. As a result, practitioners should frame documentation as part of client care, ensuring it is accurate, complete, and respectful. For example, practitioners should note relevant behavioral shifts, even if they initially seem trivial, as these may reveal underlying therapeutic insights.
Managing Documentation Challenges
If you’ve discovered gaps in your record-keeping practices, it’s never too late to adjust. Prioritize updating documentation when there’s a records request, starting with current clients and focusing on those with immediate needs. Avoid the burden of retroactively filling all records at once; instead, create a manageable plan that ensures ongoing compliance and thoroughness.
Documentation practices are evolving, and as group practices grow, maintaining comprehensive records will improve client care and align with both legal and ethical obligations. Equipping teams with resources on effective note-taking, such as training “Rethinking Notes: Strategies for Making Documentation Simple and Meaningful,” can also ease concerns about the process. Clear documentation practices will ultimately enhance the therapeutic process, fostering trust and care continuity for all clients.
Want More Resources?
- CE courses: How We Need to Give Clients Access to Their Records, Now and in the Future (2 legal-ethical CE credit hours) and/or Rethinking Notes: Strategies for Making Documentation Simple and Meaningful (2 legal-ethical CE credit hours
- Group Practice Tech podcast, Episode 418: Four Things You Need to Know About Psychotherapy Notes
- Group Practice Care Premium
- weekly (live & recorded) direct support & consultation service, Group Practice Office Hours — including monthly session with therapist attorney Eric Ström, JD PhD LMHC
- + assignable staff HIPAA Security Awareness: Bring Your Own Device training + access to Device Security Center with step-by-step device-specific tutorials & registration forms for securing and documenting all personally owned & practice-provided devices (for *all* team members at no per-person cost)
- + assignable staff HIPAA Security Awareness: Remote Workspaces training for all team members + access to Remote Workspace Center with step-by-step tutorials & registration forms for securing and documenting Remote Workspaces (for *all* team members at no per-person cost) + more