Documentation, Record Keeping, and Scope of Practice
What to document
Records should let another clinician reconstruct your reasoning. Document the informed consent discussion and its scope, the assessment and screening findings, the treatment plan and goals, the induction and techniques used, the patient's response, homework assigned and reviewed, any adverse events and management, and the plan for next steps. For memory-related work, note explicitly that accuracy limits were discussed. Keep records secure, retain them per jurisdiction and employer policy, and know the rules for releasing them, including requests from legal parties.
Scope of practice
Practice within your license, training, and supervision. Know when to refer - for diagnostic uncertainty, worsening psychiatric symptoms, medical red flags, or requests outside your competence such as forensic memory work. Do not present hypnosis as a licensed specialty you do not hold, and do not supervise or teach techniques beyond your own competence. Coordinate with other providers and record that coordination.
Traps
Items imply that brief notes suffice for hypnosis sessions, or that consent documented once never needs revisiting. Another trap is treating scope of practice as identical across professions; the correct answer usually emphasizes the clinician's own license and training. Watch for answers that permit releasing records without proper authorization.
Rule of thumb
Write notes as if a colleague must continue your case tomorrow and a regulator will read them next year - both should find the consent, the reasoning, the response, and the plan.
Worked example
After a session with unexpected dissociation, the note should record the technique, the observed reaction, grounding steps taken, the patient's state at departure, consent for the next step, and the referral plan.