Psychologists who provide health care services to patients/clients are expected to keep an accurate record of their evaluation and treatment services. A written evaluation and treatment record is the best way for a psychologist to make professional decisions about the patient's needs, for the patient to have access to an accurate personal history, and for the psychologist to reference if complaints are made about the patient's diagnosis or care.
Patients/clients have a right to expect that the psychologist's records will contain the information needed to support claims made to third party insurers if the basis of their payment arrangement with the psychologist includes insurance reimbursement. When that is the case, the information that is commonly sought by third party insurers for their subscribers includes a diagnosis based upon specific features and a treatment plan that is appropriate to that diagnosis. They usually seek information regarding the frequency and length of treatment, method of treatment, treatment goals and prognosis.
Psychologists would be wise to be aware of the usual treatment approaches in the community in which he or she practices, even if they provide a different method of treatment. This will enable the psychologist to reassure the patient who may have inquiries, the third party payer who represents the patient, and others who have reason to inquire. It may also prevent unnecessary complaints against the psychologist.
Psychologists who use specific diagnostic classification systems, such as the DSM-IV, for recording diagnosis should be familiar with the theory and methodology of such systems since such codes have specific meanings to the various groups that use them.