Practice Policy 5: Record Keeping

Printer-friendly version

  1. Psychotherapists are expected to keep appropriate records of their work with Clients unless there are good and sufficient reasons for not keeping any records. All records should be accurate, respectful of the Client and colleagues and protected from unauthorised disclosure.
  2. The Psychotherapist must ensure that any records made in whatever form are kept secure so that only authorised persons can gain access to them, in the furtherance of the psychotherapy. It is necessary to obtain signed consent to audio or video recording of psychotherapy sessions.
  3. Any records should be kept securely and adequately protected from unauthorised intrusion or disclosure.
  4. Psychotherapists should take into account their responsibilities and the rights of Clients under data protection legislation and any other legal requirements.
  5. Records must be archived safely and securely for a period of time after the end of treatment and must later be destroyed securely. CSRP recommends archiving records for a period of five years, and Psychotherapists are advised to be aware of and comply with any obligations that differ from this according to insurance, agency or statutory requirements.
  6. Records of work with young people should be archived securely for a period of time after they reach adulthood. CSRP recommends archiving records for seven years after they reach adulthood, and Psychotherapists are advised to be aware of and comply with any obligations that differ from this according to insurance, agency or statutory requirements.
  7. Clients must be informed of the keeping of written notes, how and when they are archived and of the Psychotherapist’s duty to respect the privacy of those notes.
  8. The Psychotherapist is expected to comply with requests for access to case records which fall within the terms of the Access to Health Records Act 1990, the Data Protection Act 1998 and other relevant legislation.
  9. In the context of working with couples, both partners have to give consent for access to records. Therefore, records of any individual work should be recorded separately.