ABSTRACT

Martin’s previous client had been very distressed at the end of her session and he was pleased that he gave himself 15 minutes between appointments. It had been quite an emotional session and he had felt very drained at the end. He had jotted down his notes, which he would write up later. He kept his own notes in his client file at the surgery and he put a very brief comment on one of the patient cards in the surgery notes. This was never detailed but simply provided the GP with information as to whether the client was attending and what was discussed in general terms. So he might write: ‘family issues explored’, ‘focus on work-related difficulties’, ‘explored plans for the future’, ‘mood lifting a little’.