ABSTRACT

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 downloadable resources 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.

chapter 1|3 pages

Purposes of Clinical Records

chapter 2|15 pages

Documenting Informed Consent

chapter 4|18 pages

Confidentiality in an Electronic Age

chapter 5|15 pages

Exceptions to Confidentiality

chapter 7|23 pages

Boundary Challenges

Impact of Electronic Communication on the Therapeutic Relationship

chapter 8|9 pages

Retaining and Destroying Inactive Records

chapter 10|15 pages

Clinical Supervision Records

chapter 11|6 pages

Teaching Record Keeping