Avoiding Liability Bulletin – November 2005

… Therapists and counselors should recognize that good record keeping practices will often serve to protect both the practitioner and the patient/client. The records may be used in litigation to attempt to prove or support the patient’s case, and a failure to keep adequate records may prove costly to the patient. Records are also important when the therapist’s professional conduct is being questioned. Therapists who keep good records are generally better able to defend themselves if accused of wrongdoing. Some state laws specify or mandate the content of clinical records, while other states essentially leave content largely to the discretion of the practitioner.

One aspect of record keeping, too often neglected, involves the obtaining of records concerning treatment of the patient by other practitioners or health facilities occurring prior to the time the therapist or counselor sees the patient. How often do you seek prior records of hospitalization? What about treatment records from other therapists – do you routinely or ever request them? Therapists and counselors should not forget to obtain prior treatment records in those cases that they deem it clinically necessary or appropriate. Remember, the failure to obtain prior treatment records can lead to liability. A judge or jury may find that the failure to obtain prior records in a particular case amounted to negligence.

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Richard Leslie

Richard S. Leslie is an attorney and acknowledged expert on the interrelationship between law and the practice of marriage and family therapy and psychotherapy. Most recently, he was a consultant to the American Association for Marriage and Family Therapy (AAMFT) and has written articles regarding legal and ethical issues for their Family Therapy Magazine. Prior to his work with AAMFT, Richard was Legal Counsel to the California Association of Marriage and Family Therapists (CAMFT) for approximately twenty-two years. While there, he also served as their director of Government Relations and tirelessly advocated for due process and fairness for licensees and applicants.

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