Record Keeping in Psychotherapy and Counseling

Protecting Confidentiality and the Professional Relationship

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Record Keeping in Psychotherapy and Counseling provides an essential framework for understanding record keeping within legal, ethical, supervisory, and clinical contexts. Compelling case examples identify dilemmas and strategies in protecting confidentiality. More than a simple reference book, this text introduces the concept of using records as therapeutic tools to strengthen the therapeutic relationship and facilitate clinical supervision. Appendices and an accompanying CD offer sample forms. A reader-friendly style makes this new edition appropriate for undergraduate and graduate students. New material on electronic records, the impact of electronic communication, and practitioners’ experiences with implementing the Health Insurance Portability and Accountability Act bring this book up to date. Everyone from students to seasoned practitioners will continue to rely on it for protecting themselves, their patients, and their trainees.

Table of Contents

Introduction. Purposes of Clinical Records. Documenting Informed Consent. Characteristics and Contents of Good Records. Confidentiality in an Electronic Age. Exceptions to Confidentiality. Developing Policies and Procedures for Protecting Confidentiality and Managing its Exceptions in an Electronic Era. Boundary Challenges: Impact of Electronic Communication on the Therapeutic Relationship. Retaining and Destroying Inactive Records. Using Patients' Records as Therapeutic Tools. Clinical Supervision Records. Teaching Record Keeping. Psychotherapists and Records in the Legal System. Planning for Interruptions or Closure of Psychotherapy Practices. Epilogue. Appendix A: Sample Client/Patient Information. Appendix B: Sample Treatment Plan Form. Appendix C: Sample Revised Treatment Plan Form. Appendix D: Sample Closing Summary Form. Appendix E: Sample Consent for Treatment of Minor Child Form. Appendix F: Sample Authorization for Release of Information Form. Appendix G: Sample Clinical Supervision Contract. Appendix H: Sample Informed Consent Statement for Mental Health Evaluation in a Personal Injury Case. Appendix I: Sample Letter from a Psychotherapist to a Judge in a Child Custody Case. Appendix J: List of Selected Professional Organizations and their Web Sites. Appendix K: Contents of Accompanying CD.

Reviews

“Ellen Luepker gives her readers the best of both worlds – a masterful synthesis of contemporary regulatory requirements grounded in clinical sensitivity and wisdom.” - Jon G. Allen, PhD, senior staff psychologist, The Menninger Clinic; professor, Baylor College of Medicine, Texas, USA

“I have used the first edition for years to teach therapists and case managers the basics of good record keeping, and this new edition updates and adds depth…The chapter on ‘Teaching Record Keeping’ should be required reading for every social work and counseling school in the country. This is must reading for anyone who is called to court to testify or who wishes to become an expert witness or develop a forensic practice.” - R. Keith Myers, LICSW, vice president, Clinical and Training Services, Wellspring Family Services; affiliate faculty, University of Washington School of Social Work, USA

“Ellen Luepker’s work provides a remarkably complete and readable volume on the current processes concerned with clinical record-keeping and confidentiality. Whether a student, teacher or clinician, this book is a must-have resource for practice information.” - Barbara Berger, PhD, Institute for Clinical Social Work, Illinois, USA

Praise for the Previous Edition

“This book is a lively, reader-friendly compendium of essential knowledge for every clinician that provides specific advice and examples of clinical records while illuminating a wide spectrum of legal, ethical and complex clinical issues.” - Judith Wallerstein, PhD, author, The Unexpected Legacy of Divorce

“Within an ethical and most professional framework…this book assists therapists in meeting regulations for record keeping while at the same time assuring ways to protect the client. It will become an important resource for psychotherapists.” - Florence Lieberman, DSW, professor emerita, Hunter College School of Social Work, USA

“Rooted in 30 years of experience with patients, Ellen Luepker provides detailed practical guidelines and especially wonderful examples of how to keep written records that actually improve therapy and meet the requirements of the legal system. Practicing therapists will find [this] detailed guide to be one of the most useful books they read all year.” - Thomas T. Frantz, PhD, professor of Counseling Psychology, University at Buffalo, USA

“Ellen Luepker has finally made practical common sense out of the thicket of clinical, ethical, and legal requirements for record-keeping. For HIPAA implementation, this should be on the ‘must read’ list of every practitioner!” - Hubert H. Humphrey III, JD, former Minnesota Attorney General

“Luepker’s book comprehensively and competently addresses an urgent need in contemporary mental health practice, and deserves a place in the libraries of community mental health practitioners, clinicians in private practice, social work educators and professionals from related fields of practice.” - Lana Sue I. Ka’opua, PhD, associate professor, Cancer Prevention and Control Program, University of Hawaii Cancer Center, USA

Author/Editor Biography

Ellen T. Luepker, MSW, BCD, is a licensed psychologist and clinical social worker in private practice, and an instructor in the University of Minnesota School of Medicine, Department of Psychiatry. She provides training to mental health professionals nationally and abroad on ethical issues and consultation to regulatory boards and attorneys regarding malpractice cases. She was honored by the National Academy of Practice as a Distinguished Practitioner, by the National Association of Social Workers as a Social Work Pioneer, and received Smith College’s Day-Garrett Award for her contributions to professional standards in mental health care.

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