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Documenting the Provision of Services

Disclaimer: Law, rules and regulations, not Guidelines, specify the requirements for practice and violating them constitutes professional misconduct. Not adhering to this Guideline may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations.

3. Documenting the Provision of Services

3.1
Maintain written records related to all substantive contact with clients, including:
 
  1. Reason for initial contact, preliminary assessment, and subsequent disposition.
  2. Comprehensive psychosocial assessment of problem, including, if appropriate, clinical diagnosis and reasons to support that diagnosis.
  3. Initial plan for service, including specific goals and the interventions related to each goal.
  4. Dates of service and issues of significance discussed during each contact with client, including specific actions to be taken related to those issues, if relevant.
  5. Discharge summary, including specific notation of any plans for future treatment and/or referral or circumstances under which a client stops using services against your advice (see Guideline 1.3) or because you are leaving the agency and/or practice (see Guideline 1.4).
  6. Specific steps taken at any time during the course of service to assess and treat issues of potential danger to the client and/or others, e.g., suicide or homicide.
  7. Any consultations with other professionals, including reason for consult and outcome, and client's authorization to release information.
3.1
Maintain all paper and electronic client records in a secure area accessible only to authorized persons and in a manner that lends itself to substantiating the records to be trustworthy and unalterable.
 
3.1
Be aware of retention requirements for client records, including the period required by law, and plan to retain longer when deemed appropriate.

Citations of Pertinent Law, Rules or Regulations: