ABSTRACT
Effective record keeping promotes a positive therapeutic alliance and improves treatment outcomes when clinicians’ work with their patients reflects respect, concern, and collaboration. Few mental health professional organizations or state laws define and describe the characteristics involved in competent clinical record keeping. There is little written about the therapeutic process of record keeping. More therapists are anticipating retirement or leaving their practices for other reasons and must make advance plans for their patients’ records. The need for knowledge and methods in record keeping has never been more urgent. Records facilitate communication between therapists and clients. Inviting patients to discuss diagnostic impressions and treatment options and to contribute their own perspectives, including on what is helpful and not helpful in their treatment, can help create an atmosphere of safety and mutual respect. Records form the basis of sound diagnoses and appropriate treatment plans. Reviewing records over time allows therapists to identify significant patterns and modify diagnostic hypotheses and treatment plans.
