Record Keeping, Documentation, and Confidentiality
Core concepts
Documentation must be timely, objective, factual, and relevant. Know what belongs in a record (dates, observations, interventions, referrals, outcomes) and what does not (opinions, hearsay, speculation). Understand FERPA (education records, parent access, amendment rights), HIPAA where applicable, and the distinction between sole-possession notes and official records. Know retention, release of information, and the limits of confidentiality with minors.
Traps
Questions may reward objective behavioral descriptions over subjective labels. Avoid documenting opinions ("student was manipulative") or information that could harm if disclosed without need. Watch for answers that share information without consent or legal authority, and for confusing FERPA with HIPAA. Also know that "sole possession" notes must be kept private and not shared to retain that status.
Worked example
Instead of writing "student was angry and disrespectful," document "student raised voice and left the room after being asked to wait; returned after five minutes." Objective description is defensible and useful.
Rule of thumb
Write as if the family and a court will read it: factual, dated, necessary, and free of labels.