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
Note taking is one of those big, hairy, worry-making aspects of our work. We all have to do it, and many of us wonder if we are doing it right.
The CRPO has set out general practice standards. But these standards are open to interpretation, too. And sometimes we have special cases or outliers that the standards don’t cover.
In 2017, I had a phone conversation with CRPO Practice Adviser, Lene Marttinen, to ask some questions about note taking. I’ve captured my sense of the our conversation in a four-part blog series. I hope what I learned will help clarify some questions you might have as well.
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 email@example.com.
Part 1: The Essentials
Let's define our terms: What is a clinical record vs a session note vs a non-session note?
- The clinical record is everything you need to have documented about your client, including session notes and non-session notes (e.g. their contact info, medications, date of birth, etc.)
- A session note is your tracking of information about each session
- Non-session notes track out-of-session contact and information, such as emails, texts, and phone messages that go beyond logistics of booking sessions. Some examples include: if clients offer gifts, if you have accidental meetings outside session and other incidentals considered important to the therapeutic process, and/or any issue you are addressing in supervision that requires extra documentation regarding your client’s therapeutic process (e.g. if the client is suicidal, you need to document the resources and plans you have put in place, the consultations you have undertaken around what to do, etc.)
The context of clinical records and session notes
- Clinical records and session notes are a common, accepted standard in the healthcare profession
- Clinical records are guided by PHIPA requirements (Personal Health Information Protection Act)
- This act is written in legalese, so if you want to know more, you can use two websites that translate it into lay-person language. Google the following:
- Personal Health Information is a legal concept: it’s about protected information under law
Tip: The Office of the Information and Privacy Commissioner of Ontario has a lot of great resources to help people understand the PHIPA.
The essential CRPO checklist gives you a general guideline about what to document. It’s is comprised of two pages. Earmark them in your browser to be sure you are meeting the CRPO Standards of Practice for note taking:
Why do we need to take session notes?
First, to track our process with our clients:
- Notes help us track our clients’ states and progress of our work together
- In case our notes are requisitioned by a court or, with the client’s permission, an insurer
- Session notes guide us if we are within a circle of care with other health professionals
Second, for your protection as a psychotherapist:
- Notes can protect you if there is a complaint with the CRPO
The CRPO is there to protect the public, which means it’s incumbent on RPs to protect themselves. In the event of a CRPO inquiry into a complaint, RPs must show that they have done their due diligence in supporting the client. Our session notes need to show that we communicated effectively with the client, assessed risks, set good boundaries, provided appropriate resources and safety plans, consulted with supervisors when we were in doubt, contacted the appropriate resources in cases where we have a duty to report, etc.
- The clinical record holds important information in case of emergency
- e.g. who to contact, who is the decision maker, what medications the client takes, their current mental/emotional states, etc.
Important overarching tip from the CRPO: seek legal advice when you’re unsure about anything that relates to confidentiality and disclosure.
Do we have to give up our notes if a lawyer or insurer asks for them?
Not necessarily. Get legal advice before you give up your session notes to a lawyer or an insurance company (more on insurers later in the series). A judge can order you to relinquish your notes, but you may have leeway as to how you submit them: e.g. you might be able to submit a report that summarizes your work with the client (or you might have to submit the session notes as they are). Apparently, therapists have the power to challenge a request for session notes in court if the therapist deems, in their clinical opinion, that the notes could have a potential adverse effect on the client if disclosed. Get legal counsel to be sure. As members of the OSRP, you have a certain amount of legal advice covered in your liability insurance for such queries.