Records: what to write and who will read them
Write for the colleague covering next week, the auditor, and the patient.
In many jurisdictions patients have a statutory right of access to their records, and increasingly they exercise it. That is a discipline rather than a constraint: it discourages speculation, contempt and jargon, all of which are common in records written under the assumption that nobody will read them.
What a defensible record contains
- 1What the patient reported, in their words where it matters.
- 2What you observed, distinguished from what you inferred.
- 3Measures administered and their results.
- 4Your clinical reasoning — not only your conclusion.
- 5Risk: assessed, what was found, what you did, and why. Every session, even when the answer is that nothing has changed.
- 6Consultation obtained, and what was advised.
- 7The plan, including what would trigger a change of approach.
Process notes
In several jurisdictions psychotherapy process notes kept separately have heightened protection from disclosure — but only if they are genuinely separate and contain none of the information required in the record itself: diagnosis, dates, modalities, results, plan and risk. Notes that mix the two lose the protection.
Retention
Retention periods vary substantially by jurisdiction and by patient age at the time of treatment. Know yours, and have a policy for what happens to records if you become unable to practise.