Record-Keeping, Documentation, and Retention of Client Records
The record is a legal document
Clinical records support continuity of care and are the primary evidence in a complaint, audit, or lawsuit. A complete record typically includes intake and demographic data, informed consent and releases, assessment and diagnosis, a treatment plan with measurable goals, progress notes for each session, consultation and supervision notes, collateral contacts, risk assessments, a termination summary, and a log of disclosures.
Write notes that are timely (same day or within the period the rules or policy require), objective, and behaviorally specific. Avoid speculation, labels, and editorializing; quote when it matters. Use a consistent format such as SOAP or DAP, and record medical necessity, the client's response to intervention, and the plan.
Corrections: never erase, white out, or delete. Draw a single line through the error, write the correction, date and initial it, and note why. Electronic systems should preserve the original entry with an audit trail.
Retention: Board rules and federal or state requirements set minimum retention periods, and records of minors are generally kept longer than adult records. Before destroying records, confirm the retention period, honor any pending legal hold, and destroy securely. Records belong to the practice, but clients retain rights of access and copies.
Traps
Releasing the entire file in response to a narrow request rather than the minimum necessary; including psychotherapy notes in a routine release; recording opinions about third parties; and failing to document consultations.
Rule of thumb: write every note as though the client, a judge, and the Board will all read it.