When you work in the mental health industry, there are a lot of ways to ensure that you're giving your clients a valuable service that they will genuinely benefit from, and one important thing to remember is that client notes should always be kept up to date. In fact, proper client records are crucial for a number of reasons, none of which should be overlooked:
Ensure that Your Client is Benefiting From Your Time
Up-to-date clinical records allow you to efficiently review past notes, prior to the next session, to ensure progress and help guide the conversation.
With a lot of clients passing through your practice every day, it can be difficult to remember the exact details of every case you have worked with; records are one way to ensure that everything you discuss within a therapy session is both relevant and productive.
Client Notes Can be Requested for Legal Purposes
Generally speaking, the confidentiality of a client's clinical progress notes is a top priority, they may be requested for legal purposes. The convenience of having all documentation at your fingertips and readily available, is priceless.
Although it may seem unlikely, consider what would happen if a client chose to make a claim against you and you didn't have detailed progress notes to help back up your defense. This sort of scenario should always be prepared for; after all, it's much better to be ready for something that never happens, than unready if it does occur!
If Your Client Moves to Another Therapist, These Notes Could be Invaluable
In case of a special circumstance, such as relocation, your client may request their records. A practice management software allows you to quickly locate, compile and print or email all of the required documentation. If the documentation needs to be in a paperless format, having it stored electronically makes the process of gathering and forwarding such information, seamless.
Studies show that electronic record keeping results in more efficiency, higher levels of accuracy and overall patient and clinician satisfaction. It allows you to focus on what you do best! So if you've been a little slack in the past, take some time to bring your clinical progress notes up-to-date!
