Record-Keeping & Documentation

The Professional Practice Standards regarding record-keeping and documentation.

Effective record-keeping is vital for client care, enabling therapists to track progress, make adjustments, and defend decisions when needed. Registrants must follow PHIPA regulations, maintain clinical, appointment, and financial records, ensuring clients' rights to access and correct their health information are respected.

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Introduction

 

Secure and appropriate record-keeping is essential for good client care. The client record enables a registrant to keep track of what was done and what was considered by the therapist. It may also provide information for other therapists and professionals who may provide services to the same client. It enables the registrant to track progress, note changes in a client’s condition, and adjust the therapy plan if needed. Records also allow a registrant to explain and defend what was done, if and when required.

 

Records are important for both clinical and operational aspects of practice. Registrants should keep the following types of records which are all part of the client record:

 

    • clinical records;
    • appointment records; and
    • financial records

 

When preparing and maintaining records, Registered Psychotherapists are subject to the Personal Health Information Protection Act, 2004 (PHIPA). PHIPA governs therapists’ use of personal health information, including its collection, use, disclosure and access.

 

A health information custodian is the person or organization responsible for maintaining health records. If practising alone, the registrant is the health information custodian of their clients’ records. If a registrant is working in an employment situation, they are expected to follow the record management practices of their employer. This assumes that the employer’s record management practices comply with PHIPA. If this is not the case, the registrant must ensure that their clinical records comply with PHIPA. The organization may have an information officer to monitor compliance with PHIPA.

 

Under PHIPA, clients have a right to access their own health records and to correct errors in them. While records are not written primarily for clients to read, they should be legible and understandable to readers, including the client, insofar as is reasonably possible.

 

Clients not satisfied with the way their records have been maintained or shared have a right to make a complaint.  In addition, clients have the right to require that inaccuracies in their health record be corrected. Registrants should inform clients of their right to complain to the College and/or the Information and Privacy Commissioner.

 

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