The Council is increasingly concerned that the content of client records is significantly below the accepted professional standard. The standard is quite varied, and often so poor, that Council is taking this opportunity to remind psychologists of their obligations under the profession’s codes and guidelines.
When a complaint is received, the Health Care Complaints Act gives the Health Care Complaints Commission (HCCC) power to require a psychologist to produce any client record that would assist the Commission in its assessment. Psychologists are nearly always required to submit the complete client record associated with the complaint. These records are then provided to the Council. Unfortunately, the content in many cases is often poor, regardless of the qualifications and experience of the psychologist, and even when the original complaint itself is not sustained.
When record keeping is poor, clients are placed at significant risk. Psychologists require accurate information on which to base the provision of effective services. Psychologists will struggle to monitor their work and are at risk of delivering substandard services when treatment plans, service provision and client progress are not adequately documented. Inadequate records are similarly problematic in circumstances when a psychologist takes over responsibility for a client in a multidisciplinary setting or when a psychologist is unable to provide continuing treatment.
Good record keeping serves a protective function for the psychologist should an issue arise that leads to a complaint. If client records are significantly below the accepted professional standard, the psychologist will struggle to defend him/herself if the service provided has not been appropriately documented. The Council may find it difficult to reconcile the psychologist’s version of events when it is not supported by the client record. Further, when matters progress to Tribunal, prosecutors can seize on poor record keeping as being indicative of the overall standard of the psychologist’s practice. By contrast, good record keeping is proof of compliance with professional, ethical and legal obligations.
The Australian Psychological Society’s Code of Ethics, which has been adopted by the Psychology Board of Australia as the code for the profession, requires psychologists to make and keep adequate records. The meaning of “adequate records” is expanded on in the APS Ethical Guidelines on record keeping which complement the code.
First, client records should be legible. Many psychologists continue to make handwritten notes during and after sessions. As these notes form part of the client record, it is critical that they can be easily read by the psychologist and, when necessary, by other psychologists or professionals.
Second, client records should be intelligible, meaning that another psychologist should be able to understand what is being communicated in the record. This is especially important if the psychologist writes notes during the client session and these notes become the only record of what occurred. For example, actual statements and paraphrases of statements made by clients need to be identified as such. The reader should not have to guess whether the words recorded are the psychologist’s or the client’s. The record should also be clear as to what is an impression, what is a tentative conclusion and what is a supported conclusion. For example, notes such as “PTSD???” are incomprehensible to a reader who was not present in the session and potentially could be criticised under cross-examination as indicative of poor practice.
Third, client records should be completed in a timely manner, that is, completed as soon as possible after the service is provided. This ensures accurate recall, especially when clients are seen back-to-back in a busy practice.
Finally, psychologists should maintain complete records of psychological services in sufficient detail to permit planning for continuity in the delivery of services. This does not mean that every word and action that occurs in an episode of service needs to be recorded. Unnecessary and irrelevant detail should not be included. Determining what should be included in a “complete” record will vary depending on the specific professional setting. However, as a guide, when the Council audits client records, there is an expectation that the following will be present:
The client file should include:
- Identifying data
- Contact information, including next of kin
- Fee and billing information, including the client’s consent to financial arrangements, cancellation policies and non-attendance fees
- Documentation of informed consent or assent for treatment, including signed consent forms
- Documentation of confidentiality and practice arrangements
- Documentation to and from third parties relating to the provision of services (e.g. referral letters, mental health care plans, letters to general practitioners, etc).
The initial client record following an assessment should include:
- Presenting complaint, diagnosis or basis for request for services
- History of presenting complaint including response to previous interventions, as well as any relevant history (e.g. developmental, health, forensic, etc)
- Results of formal psychometric assessment when undertaken
- Case formulation and/or diagnosis supported by evidence
- Plan for future services.
Each subsequent substantive contact with a client should include:
- Date of service and duration of session
- Type of service provided (e.g. consultation, assessment, treatment, training)
- Formal or informal assessment of client status, including risk to self or others when relevant
- Response to the intervention to date
- Detail of the intervention provided at this contact
- Plan for future services.
In summary, when considering how much detail to include in the record, ensure that the notes are sufficiently comprehensive and accurate to allow another psychologist to read the records and continue to provide service. Keep in mind that Council, Tribunals and Coroners will assume that if it’s not written down, it did not happen.
American Psychological Association (2007). Record keeping guidelines. American Psychologist, 62(9), 993-1004.
Australian Psychological Society (2017). Ethical Guidelines. Sydney: APS.