ABSTRACT
This chapter examines the need to make competent documentation of clinical treatment central to all training. It provides specific methods of teaching record keeping. Clinical supervisors can ensure that supervision contracts routinely include careful review of, and feedback about, the interns’ or new professionals’ records. Supervisors can encourage supervisees to read sample records and evaluate their own record keeping abilities. Instructors and supervisors can help supervisees or students by providing an outline of what to include in, or exclude from, records. Supervisory sessions can begin with exploring what supervisees or students have experienced or observed during their sessions with patients. Supervisors can help supervisees or trainees to distinguish between relevant and irrelevant and useful and not useful language by continually reflecting upon a list of characteristics and contents of good records. Writing and maintaining good clinical records are central to effective psychotherapy and ethical practice.
