Eric Harris (2012), longtime legal counsel to the American Psychological Association Insurance
Trust on areas related to risk management, has described elements required for appropriate
clinical record keeping. Harris lists the following information for inclusion in the clinical
record:
Medication prescription and monitoring
Start and stop times of each counseling session
Modality and frequency (once a week, biweekly, etc.) of treatment
Results of clinical tests (including raw test data)
Summaries of diagnosis, symptoms, treatment plan, progress to date, and prognosis
Paper records must be kept under secure lock and key.
In addition to psychotherapy notes kept by clinicians, digital records should include e-mail
communications, text messages, and audio and/or video files generated from work with clients.
Every reasonable precaution should be taken to preserve the confidentiality of the digital
records. This includes use of appropriate encryption services, up-to-date virus definitions and
anti-virus software, and record storage and backup.
Maximum security passwords (and/or thumb print or eye scanners) should be used on computers
storing client information. Many states now require that client records kept on computers without
duplicate hard copy records must be made unalterable after they are entered into a computer. Good
sources of information on this area of practice include the following:
2010 APA Ethical Principles of Psychologists and Code of Conduct
APA Record Keeping Guidelines 2008
APA Division 29 Telepsychology Guidelines
Post by Day 4 a description of three ethical considerations relevant to record keeping that
psychologists may face. Describe the specific challenges that may arise because of these ethical
considerations. Then explain how you will best protect your clients’ records that are in both
electronic and hard copy formats. Explain what resources (other than those mentioned above) you
might use for up-to-date, reliable information in creating your practice with regard to client
records and their protection. Be sure to include references to any applicable APA ethical codes.
Sample Answer
