Therapist Counselling Notes and Your Client Record Keeping Guide

Updated: 26th March 2018
It’s really important for a therapist to keep client consultation records. For the vast majority of you, record keeping is a basic part of your everyday practice. Good records can help a therapist to provide a high standard of care. They maintain a continuous record of up to date information about relevant aspects of your clients’ lives and about the treatments provided. Also, they are the first thing to fall back on in the event of a claim being brought against you. Full and clear client records are essential for your therapist insurance policy to have the best chances in defending any allegations of negligence or injury. In today’s society, people are increasingly likely to take legal proceedings for compensation and it’s possible to find yourself facing an allegation either if something goes wrong, or even if you are actually completely blameless.

The importance of keeping good treatment records

You probably agree with most therapists that keeping good client records is actually a fundamental part of good professional practice and is essential for effective client care. Some specific key reasons for keeping them are:

Well kept records support you as a therapist in delivering a high standard of care to your clients. They maintain a reliable history of important information relating to your clients’ health, treatments and relevant events, rather than relying on memory.
Well maintained records will help your therapist insurance to give you the best possible defence if someone should make a complaint or a claim against you. They will confirm your account of the facts. Furthermore, they can also help to discredit false allegations against you. They are your legal evidence of what happened – and sometimes equally importantly – what did not happen. If no record is made of an event, a court could deem that it didn’t take place. In litigation proceedings, it’s often not so much a case of the client’s word against the therapist’s word but rather the client’s word against the therapist’s records. Legal professionals working with insurers may well decide on the chances of defending a case successfully from looking at the client’s complaint and the therapist’s records rather than interviewing the therapist in person.
If something were to happen to you to prevent you from continuing to provide treatment for your clients, your client records would be of great benefit to the next treating therapist to ensure continuity of appropriate care.

Completing client records correctly

We list below information which we would recommend that you include in the client records you keep.

Full name of client
Date of consultation
Details of lifestyle and medical history where these are relevant to the therapy you give
Brief description of the therapy or treatment given
Unusual reactions to the therapy or treatment given
Details of patch tests carried out, if applicable
Any contraindications you identify
Advice or recommendations you give
Relevant comments made by the client about the therapy you provide
Details of aftercare advice
Any consent forms should be kept with the record
Get your client to sign the form

General points about record keeping

Keep your client records to the point, accurate and factual. Try not to use information in your notes which would be hard to substantiate. It will then be simple to identify information that would be valuable with regard to any therapist insurance claims that may arise.

Telephone communications, text messages and emails with or about the client should be recorded in the notes.

Avoid using abbreviations, jargon, or offensive comments.

Carry out a full consultation before each therapy or treatment. You should update client information every time they visit you. If you keep paper records, ask your client to put their signature against any changes that you note.

Ensure that you continue to give your client advice and information about their ongoing therapy and care. Where appropriate, be sure to offer them any choices that are available to them.

If you are a therapist renting a room within another business, you need to be certain who owns the client records. It would make good sense to have a legally binding document drawn up which sets out clearly who has access to the records and who owns them if you stop working there. If you have a Salon Gold therapist insurance policy, you can add legal expenses cover. This will give you a valuable 24 hour Legal Helpline which will give you all the advice you need.

How long should a therapist keep client records?

The maximum time someone has to bring a claim against you is limited by a law (the Statute of Limitations) which provides a specific timescale. For a personal injury claim this is generally 3 years from the time the client became aware of a problem. In most cases of an injury due to negligence, it will be the date that the resulting injury was diagnosed rather than the date that the treatment was carried out. This date is known as the ‘date of discovery’ or the ‘date of knowledge’.

For minors it is 3 years from the date they reach 18 years of age and there can be other exceptions to the general rule, for example if a claimant does not have full mental capacity. In unusual circumstances, exclusions and exceptions can be made but only a UK court has the authority to extend the time allowed to make claims.

Depending on the type of case involved, it is possible that the expiry time for a claim to be brought against you could be 6 years. We would recommend that you keep your client records for at least 7 years from the date of the last treatment. If you have concerns about any clients, or in the case of a minor, it’s best to keep them indefinitely. If you dispose of any paper records, you should shred them or burn them safely.

Storage & confidentiality of client records

Several laws govern both how the patient may have access to their records and how a professional must handle and use information.

You should keep your client records confidential, secure, and protect your clients’ information from unauthorised disclosure. If you keep paper records, you should lock them away safely. If you keep computer records, be sure to password protect them and have a backup procedure. Also, you will need to comply with the Data Protection Act. The aim of this legislation is to control the way the data is handled and prevent it from being used unethically. It also gives legal rights to people who have their information stored on their records. You will need to register with the Information Commissioner in connection with this. Your clients have the right to request a copy of their records. Follow the procedure recommended in the Data Protection Act and keep a record of it in their notes.

We would recommend that you keep your client records for at least 7 years from the date of the last treatment. If you have concerns about any clients, or in the case of a minor, it’s best to keep them indefinitely. If you dispose of any records, you should shred them or burn them safely.

Conclusion

Client records that are concise but contain all the relevant information are essential to your therapy business. If the unexpected should happen and a client decides to sue you for damages, your therapist insurance will step in. However, it will be able to secure the best outcome for you if you can evidence the facts of what happened (and what did not happen) through good record keeping.

Counselling Gold provides insurance for counselling and psychotherapy. Salon Gold provides Insurance for beauty therapists. Holistic Gold provides Insurance for holistic and complementary therapy.