Rights and Responsibilities of Psychologists and Clients – Record Keeping

Institutional, financial and legal obligations

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A fundamental aspect of the ethical practice of psychology involves clearly defining the rights and responsibilities of both the client and the psychologist as they engage in the collaborative task of therapy. These guidelines permeate all phases of the treatment relationship and represent issues paramount for protecting all parties and serving the best interest of the client. The topic encompasses both moral and legal issues, including informed consent, record keeping, involuntary hospitalization, malpractice, confidentiality, and the duty to warn and protect.

Record Keeping

Adequate and accurate record keeping is a serious professional issue which encompasses legal, ethical and clinical responsibilities. According to Corey, Corey and Callahan (2002), “Maintaining thorough clinical notes has a dual purpose: (a) to provide the best service possible to clients, and (b) to provide a basis for safeguarding practitioners in the event of a lawsuit by documenting their decisions and the actions they have taken” (p. 163).

Other professionals cite various additional reasons for conscientious record keeping, including the fact that maintenance of appropriate records may also be relevant for a variety of institutional, financial, and legal purposes. State and federal laws often require maintenance of standardized records for certain kinds of psychological services. Additionally, adequate records may be a requirement for the receipt of third-party payment for psychological services (American Psychological Association, 1993).

In keeping with the general principle of providing the greatest benefit to the client, accurate records allow a therapist to document and review the delivery and progress of psychological services. Conscientious record keeping also allows psychologists to guide, plan and implement an appropriate course of treatment, to review work as a whole, and to self-monitor more precisely. For continuity of patient care, records can provide a history and/or current status in the event that a patient seeks additional psychological services from another psychologist or mental health professional.

The nature, content and extent of each client record will vary depending upon the type and purpose of psychological services and the individual circumstances of the case. However, the American Psychological Association provides guidelines for providers of psychological services with specific advice regarding (a) the content of records, (b) the construction and control of records, (c) retention of records, (d) outdated records, and even (e) disclosure of record keeping procedures (American Psychological Association, 1993).

Therapists are often concerned that the sensitive information in patient records will be required to be disclosed against the wishes of both the psychologist and client, and furthermore, may be released to persons unqualified to interpret such records. The APA cautions psychologists to assume that no record can be guaranteed free from disclosure, regardless of the wishes of the client or the psychologist.

Ethical issues involving aspects of the rights and responsibilities inherent in each role of the therapeutic relationship can be complex and controversial. While the basic mandate of acting in the best interests of the client seems straightforward, in practice, it can require challenging professional assessments and judgment calls, and is thus subject to debate and conflicting interpretation. The issues are further complicated by the various legal standards and requirements related to patient issues. Practitioners must be firmly grounded in their professional standards and clearly demonstrate their continued commitment to serving the psychological well being of their clients, even when, or more precisely, especially when, difficult ethical dilemmas arise.

REFERENCES

American Psychological Association. (1993). Record keeping guidelines. Vol. 48, No. 9, 984-986. http://www.apa.org/practice/recordkeeping.html

Corey, G., Corey, M. and Callahan, P. (2002). Issues and ethics in the helping professions (6th ed.). Pacific Grove, CA: Brooks/Cole Publishing Company.

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