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
Special cases always show up. We’re here to help you feel prepared to document them.
The following information is drawn from a phone call I had with the CRPO’s practice advisor in 2017.
Before I start, DISCLAIMER: Please do your own due diligence when you have questions or issues that could put you or your clients 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 firstname.lastname@example.org.
Important Overarching Tip from the CRPO: seek legal advice when you’re unsure about anything that relates to confidentiality and disclosure.
How do you take notes in an environment where protecting the clients’ safety requires higher-than-usual confidentiality measures: e.g. if you work in a women’s shelter and/or facilitate a group for clients at risk?
CRPO Response (paraphrased)
Bottom line: all client contact must be documented. As a member of the CRPO, you are required to keep clinical records (which includes session notes); if you don’t keep contact information and session notes, you are not meeting the Standards of Practice.
That said, the CRPO recognizes there are contexts that require more levels of safety for clients. For instance, if you run groups in places where clients have high-risk situations in their homes and lives, you might keep bare-minimum session notes to protect the client. The following are some good suggestions for group notes:
- At the very least, track when the therapy group occurred, themes discussed, group interactions, etc.
- The session notes don’t have to be about the individuals in the group
- The therapist can hive off sections within the session notes for individual client notes, but if the therapist doesn’t want to name who participated in the group, the therapist can create a code for keeping client identities under a layer of extra protection (but you will still need to have a link to the identification information somewhere. So, ultimately, there is no way to avoid tracking clients in the clinical record; it’s our duty to do so)
- The CRPO does not dictate how to keep notes, apart from their Clinical Record Checklist, which outlines the basic requirements
Do we need to append every email, text, or voicemail from a client to our clinical record or notes?
CRPO response (paraphrased)
If the email is just an appointment email, you don’t need to append it or note it. But if it tracks out-of-session information that's germane to the therapeutic alliance and process, it needs to be noted.
The CRPO wants us to understand that there are two kinds of records you need to keep: appointment records and clinical records.
Appointment records are noted in the Standards of Practice (tip: appointment records must be kept for 5 years while clinical record must be kept for 10 years. Not sure how those two things square with each other.)
Here’s what you must record for appointments:
- Date, time, duration of session, documentation of cancelled appointments
- The CRPO doesn’t stipulate the format of appointment records, so it could be a calendar appointment, as long as it captures the above information (in electronic management systems, for instance, this information is in the client record and often also shows on the system's calendar and in each client's session note template); if you take handwritten notes, you need to add this information by hand on the session note itself
2) Clinical records
The clinical record (which includes session and non-session notes) is where we track emails, voicemails, and text messages that are material to the therapy relationship and process.
- E.g. if a client writes to you with an appointment request but includes information about their state of mind, e.g. “I’m in crisis,” then you must note this content in a session or non-session note. The CRPO says that all you need is a notation, not the email itself. BUT, anecdotally, therapists I’ve interviewed about client complaints made to the CRPO said that having the original client email made all the difference during the complaint inquiry. The CRPO is there to protect the public, not therapists. So, the OSRP recommends you append the original email to your clinical record if it contains content germane to the therapeutic alliance and process, or if the out-of-session communication raises any concerns for you around boundaries or other issues that put you at risk in an inquiry context.
- The CRPO stipulates that, in general, you need to record any interactions that are novel or unique outside of session (e.g. you might run into the client in grocery store: that would require noting if you engaged with the client. But seeing the client without them seeing you doesn’t require a note. It’s about what’s material to your work with them.)
A CRPO case study in which the therapist’s notes were deemed inadequate: The following case study is about a therapist who was disciplined: it makes clear why it’s so important to take notes, and what to document your notes.
Do we need to document consent in our clinical record for every intervention we do? For instance, if we decide to do a grounding exercise, do we need to note that we asked for and received client consent?
CRPO Response (paraphrased)
- In a word, yes, but not in so much detail all the time
First, let’s look at the informed consent process:
- Informed consent is a process and can happen in stages
- It starts with first contact with client: if a client walks into your office and sits down, that’s implied consent; At that point, we can gather very basic, high-level information
- But treatment goals may not be appropriate in the first session if you don’t have enough information about the client
- You can gather information and form treatment goals with the client’s consent over the first few sessions
- If a client is in crisis, however, consent might have to happen later -- e.g. therapeutic safety is more important as a first step
- Formal consent, however, needs to be explicit. Formal consent is about having a conversation about your contract with the client. It includes reviewing terms of service, benefits and risks of therapy, limits of confidentiality, cancellation policy, client access to their information, anything around touch, etc. And this information should be conveyed as soon as feels appropriate, but the sooner the better. And you must document that the client either said they understood or showed they understood (e.g. "client nodded")
Tip: Discussing the limits of confidentiality at the beginning of your sessions ensures your clients know what they are agreeing to before they tell their story. Having that discussion at the end of the first session, or over the course of a few sessions, risks clients disclosing something they later regret once they understand the limits of confidentiality.
Second (and the answer to our question): You don’t have to reaffirm every single treatment that has already been agreed to by your client
- For instance, you don’t need permission to explore family-of-origin territory if the person has already understood what might come up in therapy
But here is what you do have to note:
- If you make a change to your interventions or treatment goals, you have to get the consent for the change and document this consent
- There are some situations where the client will need deeper discussions, such as therapy that includes touch. Then consent is ongoing, explicit, and should be noted that you did touch with the client’s permission: e.g. If the client tensed at a particular time in session that indicated they didn’t want to continue an intervention, you’d document both your check in and the reaction you observed in the intervention. But you don’t need to document every little instance of touch e.g. if you already agreed to touch in that session, you don’t have to track each hand squeeze
Tip: after you get consent for treatment goals and how you work, what you are noting thereafter for consent are the things that are unusual, different, risky, changes in treatment, etc.
What happens when an insurance company requisitions clinical notes? Why would an insurance company need to see specific notes?
CRPO Response (paraphrased)
Sometimes insurance companies have a clause in their client agreements in which clients must agree to the company’s access to the clinical records/notes in order to receive funding.
Clients need to read their insurance paperwork to be sure they know what they are agreeing to with their insurer. That's on your client, not you. Sometimes a client has agreed to share their therapy-process information but they didn’t understand that, or remember that, or tell you about it. So it’s important when a client or insurance company asks you for clinical records that you have a conversation with your client to ascertain the following first:
- Why is the insurance company requesting this info?
- Did the client sign papers agreeing to clinical notes disclosure?
- If the insurance company wishes to speak to the therapist, the client needs to sign a consent form first
- The client may have to do their own advocacy here if they signed a form with the insurance company for access to clinical notes in exchange for coverage. The therapist will have no choice but to disclose notes if the client signed a form to disclose their clinical notes.
- Find out if you can provide a summary report instead of handing over your notes
Tip: In general, the CRPO says when it comes to disclosure, give only as much information as needed. The CRPO suggests ensuring you cover yourself by getting signed consent forms and seeking legal advice as well.
What if you have kept a separate diary of thoughts about the client that represent your opinions, theories, counter transference, etc.? Are those considered part of the clinical record? What’s the difference to the CRPO between diary notes and clinical notes?
CRPO response (paraphrased)
- Yes, you are supposed to provide a link to diary notes in the clinical record. You just need to note where to go to find that information if it’s not in the session notes.
- If a court requisitions your diary notes, you could make a case that diary notes are a place to ponder, that they are not the official session notes
- You don’t need to provide diary notes up front if your clinical records are subpoenaed; It becomes another layer of request from the court and you can argue the diary notes might not have the same relevance, or they might have an adverse impact on the client
- If there is additional information you want to track somewhere that’s not in a session note, then you’d need to keep that information for the same amount of time (10 years)
- If you take scratch notes in session that get translated into finished notes, you can dispose of the scratch notes as long as you have a signed and dated official clinical record with any changes noted in that record
Tip: CRPO suggests talking to a lawyer because it boils down to PHIPPA rules, not the CRPO’s.
Stay tuned for Part 3:Questions about the CRPO Standards of Practice, coming soon!