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:
- All activity related to the case
- All activity performed (session activity, etc.)
- Amount of time spent with client in each session
- History provided by client
- Clinical diagnosis
- Care provided to the patient (including the focus of care)
- Up-to-date treatment plan(s)
- Patient’s response to the treatment
- Patient’s prognosis/progress
- Mood, cognitions and/or behaviors of the patient at particular times
- Statements that the patient made in treatment
- 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.