How much time do I have after seeing a client to make a record of the session?
The general standard for timeframes within which one must document a session are at the time the services are rendered, or within a reasonable time after such services have been provided. There are good reasons to try to create your record as quickly as possible following a session or clinical contact. First, it is important to create accurate client records. The APA Record Keeping Guidelines (2007) state that “a psychologist strives to maintain accurate, current and pertinent records” – and accuracy will be higher if documentation occurs soon after a client contact. Second, and especially in high risk or dynamic situations, things can change quickly, and it is important to document events in a timely manner as a risk management strategy. For example, if a client develops suicidal ideation and you take time to conduct a risk assessment and create a safety plan, be sure that this is documented as soon as possible, not only to ensure that your good work and clinical judgment is documented to protect yourself, but also to provide accurate and useful records in the event the client is hospitalized or the records are required for another reason. Third, if records become subject to legal proceedings and they have not been created within a reasonable time after a clinical contact, they will not be admissible without additional steps that could cost the client (and the provider) time, inconvenience and resources. Thus, the best practice is to document client contacts immediately after they occur, and if that is not possible, strive to complete all documentation at the end of each work day.
How do I correct an error I find in a client record?
It is important to keep accurate records so that your documentation is useful and effective. If you discover an error or omission in your review of a client record, correct the record. However, you should NOT destroy the original record. In the event of omitted information, you can make an addendum to the note, indicating the date and time that the addendum was added to the record. You do not want it to appear that you have altered your record, just that you have subsequently added new information.
If you find an error in the documentation, you will again want to be transparent about the fact that the corrected information is being added after the original documentation. Again, this can be accomplished through an addendum to the note with the date that the correction is being made and the reason for the error and correction. You should avoid crossing out, erasing, or whiting out information in your record because doing so later may be used to suggest that you are covering up errors in practice, and not just record entry. Transparency is key. Be certain to explain what you are doing, why you are doing it, and the date and time at which it is done.
What is the standard for securing paper files?
The APA Record Keeping Guidelines indicate that a psychologist should take “appropriate steps to protect records from unauthorized access, damage and destruction.” In terms of storage and maintenance of records, the guidelines indicate that paper records should be kept “in a secure manner in a safe location” that provides protection from damage and destruction. The guidelines also indicate that access to paper records should be controlled by keeping the records in “locked offices or storage rooms.” This is especially important if you are taking files home with you or traveling between offices with client files. A reasonable practice would be to keep those files in a locked briefcase in your vehicle’s trunk or other secure location.
Many psychologists are familiar with the “double-lock rule,” meaning that files should be stored behind two locks (i.e., a locked storage room in a locked file cabinet). This rule is part of formal APA guidance on the matter (Guideline 6). In addition, there are organizations and entities such as insurance companies that require compliance with the double-lock rule, and it is a good practice. Further, you should become familiar with your state’s rules or policies on record storage, if any exist, because your state may have specific guidance on the matter.
Reference
American Psychological Association. (December 2007) Record Keeping Guidelines. American Psychologist, Vol 62(9), 993-1004. PMID: 18085845. DOI: 10.1037/0003-066X.62.9.993.