Records: Purposes, characteristics, and contents for protecting our clients and ourselves
As we struggle to make our way, it helps to realize we are not alone. Many psychologists express uncertainty about what constitutes good record keeping practices. (Luepker, 2003; Scaife & Pomerantz, 1999) They have not received training or support in how to manage these essential professional tasks, much less how to use records as therapeutic tools. Further, even though professional organizations highlight the importance of maintaining high standards to protect client welfare and professional ethics codes and regulatory boards specifically require records (e.g., American Psychological Association [APA], 2007; Australian Psychological Society [APS], 2004, 2007; British Psychological Society [BPS], 2008), none adequately define nor describe the characteristics of competent record keeping. Only recently have academic programs begun recognizing the urgent need to include knowledge about record keeping in psychological counseling curricula. Although some psychologists are lucky enough to learn about documentation during their clinical or counseling practice and internships, most are left to muddle through. To help fill this gap, in this Chapter I share tips on key issues in record keeping including: purposes, what to include, how to say it, how to keep it simple, and how to plan for records in the event of interruptions or closure of practice.