Recordkeeping in Private Practice

Abstract

This chapter provides critically important, up-to-date information and recommendations for the creation, maintenance, storage, disclosure, and destruction of records for mental health professionals in private practice. Records inform, guide, and reinforce the client’s treatment, and can help to secure legal benefits and employment opportunities for clients in addition to enhancing multidisciplinary care and informing clinical research. Records are also an expensive and time-consuming professional obligation that can function as a target in both legal proceedings and board complaints. Best recordkeeping practices are identified and explained from the combined perspectives of clinical service provision, ethics, and law, with particular emphasis upon such sources as the Health Insurance Portability and Accountability Act (HIPAA), the American Psychological Association’s “Record Keeping Guidelines,” and similar guidelines that have been established for psychologists, counselors, social workers, and marriage and family therapists.