Note Taking in Four Parts

Part 1: The essentials

Part 2: Special cases 

Part 3: Questions about the CRPO Standards of Practice

Part 4: PHIPA and Confidentiality

 

 

The Standards of Practice do their best to lay out guidelines, but sometimes these guidelines can feel ambiguous, confusing, or just require clarification. Over the years, I have tracked questions from colleagues about the Standards regarding note taking. I posed these questions to the practice adviser at the CRPO on a call in 2017. The article below is what I captured and understood from that call.

DISCLAIMER: Please do your own due diligence when you have questions or issues that could put you or your clients or you at risk. This blog series is the intellectual property of the OSRP and should not be copied or disseminated without the express permission from the OSRP. For more information, contact membership@psychotherapyontario.org.

Important Overarching Tip from the CRPO: seek legal advice when you’re unsure about anything that relates to confidentiality and disclosure. 

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The following questions are from the record-keeping section of the College's practice standards document.

On page 48 of the Profession Practice Standards for Registered Psychotherapists, penultimate paragraph: "Members should exercise caution when considering what information to include in the record.” Our question was: Is there information we should exclude? For instance, if the notes are subpoenaed, do we change our notes to protect our clients? 

CRPO response 

  • Any changes to your notes need to be noted and dated, along with a rationale for the change; in other words, you should not change your notes unless there is a good reason, and then you need to track those changes and account for them. 
  • The CRPO suggests we take notes with caution in mind if we know from the outset that our client is legally involved (for instance, a custody case). In these instances, it may not be in the client’s best interest for the therapist to have details that could be misinterpreted if someone else read our notes. Ask yourself, “Are there bigger-picture matters to focus on here: would it put client at risk to make this particular notation?”
  • The goal is to record information that’s relevant to the therapeutic process, but also with consideration of the this client's context

     

    In a related question, should a therapist record the full names of people the client talks about, especially if there are relational issues that might end up in court? 

    CRPO response 

    • If what’s important to the therapeutic process is the client’s relationship to conflict -- i.e., how to learn new relational skills -- then the other players are not important to note by name. You could use initials, for instance, or something more vague, such as “the client’s cousin or friend or coworker.” 
    • But if the client’s cousin is a perpetrator contravening a restraining order, it’s likely relevant to note the name of that person in relation to the client; it’s a risk factor and might end up in a legal context at some point 
    • The CRPO acknowledges that clinical notes can both safeguard or create conflict in court: so taking notes is about our judgment. 

    Tip: The CRPO recommends talking to mentors in the field about how to manage these kinds of records, and to consult with lawyers when we are in any doubt.

     

    In the Practice Standards, on page 49, paragraph 1: "The therapy plan . . . will include both subjective and objective information. Subjective information is relevant information provided by the client. Objective information is relevant information observed by the member." We asked the CRPO practice adviser to kindly clarify their definition of subjective vs objective.

    CRPO Response 

    • These terms just mean both parts of the story need to be in the session note: the client’s narrative and the therapist’s observations
      • Client narrative: gather information from the client as they report it
      • Therapist observation: document what we observe of the client, the meaning they make of something, the subtext, the context, and incorporate our observations into the therapeutic process
        • Our observations are guided by the lens of our modality, so keep that in mind, and make your modality lens explicit in your notes.
          • For instance, if you are a therapist who works in Internal Family Systems (IFS), your notes might track what you observe with the clients about the active "parts" that show up in session and how the client made sense of the parts and related to them; but because IFS is non-interpretive, the therapists would not theorize what the parts mean to the client outside the client's own interpretation of the part; however, the therapist might observe the client's presenting state (tears, appeared panicked, became dysregulated, etc.)

    The Standards of Practice are a guide. As your own practice evolves, you may wonder how to interpret something in the Standard. The CRPO has a practice adviser for just such questions. We encourage you to make use of that resource when you are unsure.

    We'd love to hear your thoughts on this these articles. Please leave a comment below and tell us your experiences, or your thoughts about what you have read here!


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