ABSTRACT
All mental health organizations have codes of ethics that highlight the paramount importance of protecting patient confidentiality and maintaining the highest professional standards to protect patient welfare. Sadly, very few mental health organizations or state laws define and describe the characteristics involved in competent record keeping. This leaves practitioners to use what little they learned in graduate schools or internships, or to devise their own policies in a virtual vacuum. However, several recent developments are challenging graduate schools, clinical supervisors, and therapists to focus on documentation. First, the federal privacy rule now requires practitioners who generate identifiable health care information electronically to develop written information that explains to their patients how they use treatment records and how they protect the privacy of those records (United States Department of Health and Human Services, 2001a). Second, increasing numbers of malpractice complaints are forcing clinicians and supervisors to create more careful documentation. Third, higher rates of litigation in our society mean that more practitioners are receiving subpoenas for patients’ records and are struggling to find ways to respond and still protect their patients’ privacy. Fourth, more therapists are anticipating retirement and must make advance plans for their patients’ records.
