Therapists are legally required to keep records, ie progress notes, for psychotherapy sessions.  No specific format (eg SOAAP notes) is required, but progress notes must be in keeping with accepted clinical standards.

Paper records and electronic records must be securely stored

Generally, records should be kept for 7 years after termination for adult clients. This is not a legal requirement per se, but it allows enough time for most statutes of limitations, in the event your ex-client should ever be involved in a criminal case where your records would be needed. If that happened and you had destroyed the records early, you would be considered negligent.

For child clients, keep records until the child turns 19 (giving them one year after the age of majority to be able to request their own records), or 7 years after termination, whichever is longer.

A client (or whoever gives consent to treatment, eg a child client’s parent) has a right to view their own records, including information in the chart from third parties. It is often clinically ill-advised to give the client a copy. Some therapists ask if the client is willing to view the records without receiving a copy. Legally the therapist has the right to give the client a summary only, and explain that viewing the entire record could cause the client emotional harm.

When giving records to a client, a therapist may charge an administrative fee for photocopying. However, it is illegal to withhold the records from the client because the client owes money for therapy services.

It is important to keep records that will be unlikely to harm your client, or other parties, in case they are viewed by the client or released to others. Therefore:

• Include only clinically relevant facts and use objective, behavioral language.
• Do not include unnecessary details about sensitive medical information eg HIV status. (Another reason to omit it is that assessing and recording medical information is outside a therapist’s scope of practice).
  
• The same goes for information that could have legal consequences, eg potentially criminal acts including civil disobedience.
  
• Leave out names, and minimize identifying information about people other than the client.
  
• Keep process notes, personal reflections, and case presentations separate from progress notes, and destroy them when they are no longer needed.
  

It is also important to show in your documentation that your own behavior was legally and ethically sound. Therefore:

• Be aware of scope of practice in writing down any medical diagnosis, taking care to quote the client or medical professional as the source. (Example: “Client stated he has digestive problems which his doctor told him could be a side effect of anti-depressants.” NOT “Client’s anti-depressants are causing digestive problems.”)
• Record the fact that you referred the client out for needs that fall outside your scope. (Example: “Discussed client’s feelings about side effects of anti-depressants and suggested he consult his doctor.”)
  
• When there is a risk of suicide or harm to others, document how you assessed the situation and why you did NOT initiate a 5150, warn a victim, contact law enforcement, etc. The same goes for NOT filing a child or elder abuse report.
  

It is a good idea to keep records of all communications with a client (not just billable sessions) and with any third parties (providers, family members, etc).

Recordkeeping

Law and Ethics Nuts and Bolts