Tips for Testifying Lesson 10: Top 12 Recommendations for Records to Be Kept by Counselors in Preparation for Trial

In a previous post on how to avoid legal problems when engaging in a new counseling relationship, we mentioned that you never know when a client will become involved in a legal dispute, like a divorce or a child custody case, that will require your participation.  Because of that, it's critical to keep client records which might be needed in a legal case.

Lesson 10: Top 12 Recommendations for Records to Be Kept by Counselors in Preparation for Trial

The counselor should keep a precise log (case notes) of the following when preparing for trial:

  1. All activity related to the case
  2. All activity performed (session activity, etc.)
  3. Amount of time spent with client in each session
  4. History provided by client
  5. Clinical diagnosis
  6. Care provided to the patient (including the focus of care)
  7. Up-to-date treatment plan(s)
  8. Patient's response to the treatment
  9. Patient's prognosis/progress
  10. Mood, cognitions and/or behaviors of the patient at particular times
  11. Statements that the patient made in treatment
  12. Use terms like "Client reports" or "Client states" in your notes

Remember that, although no one likes paperwork, keeping complete and accurate records is an essential part of your mental health practice.  Failure to document a patient's treatment and diagnosis and the failure to maintain records are offenses which are sanctionable by your regulatory board. Thank you for joining us for this blog post series, Tips for Testifying in Legal Proceedings.  If you missed any of the previous entries, feel free to take a look: Lesson 1: The Basics of Testifying in Legal Proceedings Lesson 2: How to Respond to Questions Lesson 3: Watching Out for Trick Questions Lesson 4: Direct and Cross Examination of Witnesses Lesson 5: Lay Testimony, Expert Testimony, and the Mental Health Professional Lesson 6: Who Is Qualified to Testify as an Expert Lesson 7: 10 Essential Differences Between a Therapeutic and a Forensic Relationship Lesson 8: How to Anticipate and Avoid Problems When Engaging in a New Counseling Relationship Lesson 9: The Role of the Counselor in Child Custody Evaluations If Michael Puhl can assist you in any way, please just give us a call.

No Comments

Leave a comment
Comment Information
Email Us For a Response

Meet With Michael Puhl

Bold labels are required.

Contact Information
disclaimer.

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

close

Privacy Policy

Contact Info

"We’ve moved! Please come visit
us at our new Address"

Puhl Law Group, PC
205 W. Louisiana Street
Suite 201
McKinney, TX 75069

Phone: 972-569-3166
Map & Directions

CALL:
Review Us
Rated By Super Lawyers | Michael R. Puhl | SuperLawyers.com Avvo Rating 10.0 Michael R. Puhl Top Attorney Texas Board of Legal Specialization Board Certified | Texas Board of Legal Specialization