Standard 5.1: Clinical Records

The clinical record serves as an important reference document for several purposes:

• Assisting the registrant with recalling and planning therapy, and tracking progress;
• Providing information for other professionals who may provide services to the same client; and
• In an investigation or legal proceeding, as evidence of the client’s condition and the registrant’s actions.

Registrants maintain a clinical record for each client. The complete clinical record should be stored together to avoid incomplete or lost information.

The Personal Health Information Protection Act, 2004 (PHIPA) uses the term health information custodian to describe the individual or organization responsible for managing health records. When practising alone, the registrant is the health information custodian. When an RP is working as an employee of an agency or hospital, they are expected to follow the record management policies of their employer in compliance with PHIPA. When the registrant is practising in a shared or group practice arrangement, it is important to clarify in writing at the outset who owns the records (the registrant, clinical supervisor, or group practice). In general, the health information custodian keeps the original record and provides copies when disclosing the record to others with authorization.

Key information in the clinical record is maintained in English or French. Key information includes the client profile and anything else, such as a summary, that needs to be readily accessible to other healthcare providers in an emergency. Progress notes may be recorded in the language in which therapy is taking place.

When more than one person (e.g., a couple or family) attends therapy, records may be maintained in one file as long as the couple or family attends the sessions in the same combination. When the couple or family attend in different combinations, the registrant should generally keep separate files or sub-files for each individual. For example, if one member of a couple attends an individual session, a file for the individual session should be maintained separately from the file for the couple.

Similarly, in a group therapy setting, the registrant may maintain separate files for each individual, or one file for the group. When a client in the group receives individual therapy with that registrant, the registrant maintains a separate file for that client’s individual therapy.

Registrants should explain to joint clients how records are kept and how they may access those records. Clients may access the entire record if all participants consent or submit a joint request (e.g., both members of a couple request access to the couple therapy record). If only one participant requests access to a joint record, and the others have not consented, they are only entitled to the information about themselves, and any communal information (e.g., general themes) that is not attributable specifically to another participant.

Records may be maintained in hard copy or electronic format. When maintaining a hard copy record, each entry should include the client’s name or unique identifier,[1] date, and name or signature of the registrant. Electronic records should similarly permit each entry to include the client’s name or unique identifier, date, and the registrant’s signature or initials, i.e., evidence that the registrant made the entry.

[1] A code (e.g., a number) that allows the registrant to identify that client without using the client’s name or other direct personal information. A unique identifier is one way to distinguish one client from other clients. Registrants must securely maintain a key linking each client to their unique identifier.

The following are relevant categories of information or documents contained in the clinical record.

• Client profile: The client’s full name, address, telephone numbers, date of birth, and unique identifier (if applicable). It also contains relevant information regarding the client’s legally authorized representatives (if any, as described in the Health Care Consent Act, 1996), as well as the full name and contact information of any professional who referred the client, along with the reason for the referral. If the client was self-referred, this should be noted as well.
• Assessment: A record of any therapeutic assessment, including methods used, results, conclusions, problem formulation, or other professional opinion regarding client status.
• Plan for therapy (or Therapy Plan): The plan for therapy will depend on particular circumstances including the therapeutic approach or model used. The record shall minimally indicate the plan or direction that the therapy is intended to take and log the client’s initial and subsequent consent(s) as necessary. It will also include any reports on tests administered to the client. As the therapeutic relationship continues, changes in the therapy plan will also form part of the record.
• Progress notes: Notations of client’s statements, therapist’s observations, impressions, and proposed plans in response.
• Work product: Photographs, copies, or descriptions of objects made, e.g., artwork.
• Consultations and referrals: The date and relevant details of every consultation the registrant receives from or provides to another healthcare provider, regarding the client. This would also include specific information related to any referral made by the registrant regarding the client.
• Reports: A list and copy of all reports sent or received respecting the client.
• Incident reports: For any major, unexpected negative outcome, a clear record of the incident as well as any action and follow-up.
• Mandatory reports: Registrants keep a copy of all written reports they make in complying with their mandatory reporting obligations. When registrants have only made a verbal report, they prepare a written summary of the discussion and include it in their records.
• Closing: A record of conclusion or termination of the therapeutic relationship, including reasons and an explanatory note such as a summary of outcomes attained, a record of referrals, or follow-up recommendations.

The following are generally not considered part of the clinical record.

• Rough notes: Rough notes do not need to be maintained in the clinical record, though they may be. If not retaining them, they should be used to complete the clinical record and then destroyed promptly, i.e., on the same day.
• Developmental notes: Notes on the therapist’s own process, which may be used in clinical supervision, and do not identify the client.

Every entry into the clinical record indicates who made the entry and when. When an amendment to a record is needed, the amendment should indicate what change was made, when, by whom, and why, making sure that the original entry is still legible.

Clients have a general right to obtain a copy of their personal health information under PHIPA, but this right is subject to certain exceptions under sections 51-54. Regardless of how the information is structured or stored, client records must be easily accessible and legible. Registrants may charge a reasonable cost-recovery fee. For example, a fee of $30 for the first 20 pages and 25 cents for each additional page, has been held as reasonable. The fee must not be a financial barrier to access.

Where the RP is the custodian of the clinical record, they retain the record for at least 10 years from the date of the last interaction with the client, or for 10 years from the client’s 18th birthday, whichever is later. For example, if a child is age seven at the time of last interaction, the record would be kept until the client’s 28th birthday.