ABSTRACT
Good record keeping is essential to good psychotherapy. But psychotherapists often lack knowledge about record keeping, and as electronic records become more required this becomes a larger issue. This chapter provides a model of record keeping that promotes the integrity of clinical practice, whether with individuals, families, or groups. It discusses the characteristics of good records and examines key questions that need to be answered in good records. The chapter presents essential contents of good records, and describes what should not be included in records and options for methods of record keeping. Treatment plans follow logically from diagnoses. Progress notes should show treatment geared toward resolving the stated problems and goals. The chapter outlines the essential contents of good records, which can help practitioners and their supervisees fulfill the various purposes of record keeping. Changes in diagnoses or treatment plans need to be documented in detail, with specific contemporaneous reasons for modifications.
