ABSTRACT

This chapter discusses issues related to clinical documentation or recordkeeping. It reviews professional standards and access to client records, then discusses requirements related to assessments and treatment plans, progress notes and psychotherapy notes, other client contacts, and special clinical situations. The primary reason to document treatment is for the client's welfare. Clinicians are required to meet a professional standard of care in all aspects of treatment, which means providing care that is consistent with generally accepted standards in the behavioral health field. For the purpose of quality assurance and improvement, many organizations have regular chart reviews in which records are reviewed and evaluated by a supervisor who gives feedback to improve documentation. Timeliness of progress notes is another important aspect of documentation. A progress note documenting telephone contact with the client should include the reason for having telephone contact and the content of the conversation.