Professional Record Keeping:  Part I

Over the next few quarters, the State Board of Psychology will provide you with a series of articles related to keeping and maintaining records for your practice.  Aside from assessment and treatment, record keeping is the third most critical aspect of providing effective psychological services.  In fact, at the basic level, providing psychological services forms the trilogy of assessment, treatment and record keeping.  In addition to helping you provide the optimal level of care for the client by monitoring progress, record keeping insures that if a legal or ethical complaint is filed against you, there will be clear evidence of what, where, when and in what context services were provided.  Records can help protect both you and your client in this event or if there are any billing questions from third party payees.

In order to be valuable, records must be accurate, detailed and current.  Records that are written in vague or broad terms may not be useful in the event of any type of investigation, or even for your own use. Also, a factor that is often neglected is providing a rationale for your actions.  It is difficult or impossible to second guess why you took the actions that you did after the fact.  Remember, if it’s not written down, it did not occur (or at least you cannot prove that it did occur).  Also, not having any notes or records is NOT an option for licensed psychologists.


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