Documenting Psychotherapy: Essentials for Mental Health Practitioners
This concise volume examines exactly what is involved in keeping adequate clinical records of individual, family, couple and group psychotherapy. The authors discuss: limits of confidentiality; retention and disposing of records; documentation of safety issues; client access to records; treatment of minors; and training and supervision issues. Throughout the book, legal cases, vignettes and professional commentary help readers to consider legal and ethical issues.
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The Clinical Record
Documentation of Safety Issues
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AAMFT access to records advise American Counseling Association American Psychiatric Association American Psychological Association assess assist attorney breach California Chapter child abuse reporting client client tells client's record clinical Code of Ethics consent form consult copy counseling counselor Court Decision Court of Appeals custody dangerous Decision The court Defendant diagnosis disclosure document duty to warn ethics codes evaluation Evidence Code Family Therapy guidelines harm hospital husband identifiable victim informed consent insurance company issue keeping records Kenneth Baker limits of confidentiality maintain confidentiality mandated material mental health minor negligent parents patient person plaintiffs potential privilege Professional Vignette progress notes protect psychiatric psychiatrist psycho Psychological Association psychologist psychotherapist reasonable record keeping regarding release reporting laws request responsibility session sexual Social workers spousal abuse standard subpoena suicide summary supervision supervisor therapist tion treat Treatment Plan Whitree write written