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 Section 2: Aligning Clinical Records with Mode of and Approach to Treatment 

As was noted, clinical record keeping has some important functional purposes. These purposes must be kept in mind when you choose a design for your clinical records. If the functional purposes are the driving force behind the choices you make for record keeping design, it assists you in finding the optimal balance between records that are thorough and records that are concise.

In all treatment settings, it is important that your design approach take into consideration the following important factors:

1) the kinds and amounts of information that need to be captured, detailed, and distributed so that appropriate aspects of care may be administered properly by all participating members of the treatment team, while most effectively maintaining the client’s right to privacy;

2) the use of formats that allow for effective and efficient entry and retrieval of information into and out of the case record;

3) the use of formats that align with the actual treatment approaches and techniques being utilized in treatment, with sufficient flexibility, where needed, to accurately capture the essential information when multiple treatment approaches and techniques are being utilized; 

4) the use of formats in which each of the constituent parts of the record maintains logical alignment and coordination with each of the other pieces, e.g., the assessment form records the clinical information and history that explains the choice of what clinical areas are being focused on in the treatment plan. 

There are three important components operating in our first principle. First, case records must be designed to capture and make available the right information, and the right amount of information, to serve their purposes. If the wrong information is gathered, or too little information is gathered, then the client’s care can be less effectively managed and tracked.

Second, the degree of information captured should not be arbitrarily excessive. Capturing too much unnecessary information imposes burdens on the clinician, decreasing motivation to keep good records. Third, clinicians are guardians of the privacy of the client. In a way, it is a violation of this role to include in the case record any information that exceeds what is essential to the case. Just as it protects the rights of clients to offer them the least restrictive environment possible to address their needs, it also protects their rights to keep the least amount of personal information possible within the case records.

In certain treatment settings, where the client presents with a more profound and/or complex level of problems - requiring a much higher level of care - the functional purposes can include immediate issues of life and safety. In such settings, clinicians will often be operating as part of a closely coordinated treatment team, with different parties responsible for different aspects of the client’s care, or providing similar types of care but on different shifts.

This creates a higher degree of urgency for designing clinical records that address the functional purposes well, both for supporting positive outcomes and for creating a record that limits exposure to legal liabilities. This suggests that the records in such circumstances may need to be more thorough and comprehensive, including more detailed information covering a variety of different clinical areas. The need to keep the client safe will typically push to err on the side of comprehensiveness at the expense of concision. However, the need to consider issues of privacy will still be present, and extraneous information should still be excluded from the record.

By contrast, in many private practice settings, where less complex and less risky cases are handled, it may be possible to create records that require less detail while maintaining safety and good case management. This also allows for records to be designed in ways that maximize the degree of privacy afforded to the client. Records can be kept very concise with limitations on the amount of private and personal information maintained. However, there may also be an extra complexity in designing records in private practice settings from the perspective of the first principle.

First, even clinicians who carefully screen their cases can end up seeing client’s who move quickly and unpredictably into stages of acute need. No clinician in private practice settings can predict with absolute certainty which “easy” cases might transition to more difficult, more complex or more dangerous states of being. In such instances, close contact is often needed with other concerned parties, including physicians, treatment providers working with family members, or representatives of the court, etc. It is always advisable to have ongoing working relationships with other mental health professionals and treatment facilities in the event that a case requires more intensive levels of care.

This means that these difficult and risky outpatient cases often operate within a treatment team model - but with a diffuse team, one that lacks the convenience of having all of its members working at the same location and being able to exchange information as needed from shared clinical records and face to face interaction. This places increased demands upon the records to get the right information stored so it can be distributed in useful ways, and to develop good systems for making sure that information gets where it needs to go.

The best design for this set of circumstances would be clinical records with the flexibility to move from more concise models to more comprehensive models should the need for greater information gathering present itself. This means having some parts of the treatment records that are expandable. This understanding is particularly relevant for private practice clinicians whose specialty areas include more complex and more unpredictable cases: eating disorders, substance abuse disorders, domestic violence, personality disorders, and high conflict couples.

Many clinicians under these circumstances will end up developing favored referral resources that can operate effectively and efficiently when cases move into more acute stages of problem manifestation. It is very helpful to consider how to create the best alignment with those treatment resources when considering the design of your clinical records. The key question in this case is what kinds of information in which formats will best facilitate the process of sharing necessary information with your anticipated treatment partners. This leads to the importance of the second and third principles in designing effective clinical records.

In acute care settings – at least in theory – careful consideration is given to designing records that allow for quick and effective information transfer from one member of a treatment team to another, with a design that allows for information from multiple modes of treatment to be gathered, shared and understood by all parties in ways that serve the treatment needs. For example, information from a 12-step group can be accessed and utilized by the case manager, and the case management information can be accessed and utilized by the psychiatrist engaging in medication management. With good design, the records gather the correct information to pass forward to the other members of the team in ways that allow the other team members to quickly find, see and grasp the key factors for treatment.

In private practice settings, the clinician will most often work with one or more predominant treatment models. When they enter into practice – particularly private practice - clinicians are permitted to choose the approach(es) and mode(s) of treatment that align best with their temperament, their training, and their preferences. However, there exist ethical and professional obligations towards providing treatment that not only produces actual positive results - i.e., evidence-based approaches – but which is going to be the best fit for the needs of the client.

There is also a larger principle here, one that affects not just the choice of how your clinical records are designed, but also how your treatment approaches are selected for the clients that you see. In’s course on the fundamentals of counseling, we also noted that – if a clinician wishes to operate at the highest level of ethics – he/she should be constantly asking: What treatment, by whom, is the most effective for this individual with this specific problem, and under what set of circumstances.

No matter what perspective(s) or model(s) clinicians use, they must decide who should do the counseling or treatment, what techniques, procedures, or intervention methods should be utilized, how to use them, when to use them, and with which clients. (Paul, 1967) Some people call this the who-how-whom factor, that is, what counts in counseling is who does it and how and to whom it is done. (Corsini & Wedding, 2000)

In’s course on the fundamentals of counseling, we noted that there are well over 400 theoretical counseling approaches that have been identified, but with most of the approaches grounded in five major theories:  psychodynamic, cognitive/behavioral, humanistic, transpersonal, and systemic. (Corsini & Wedding, 2000, Hackney & Cormier, 2005) The design of your clinical records will be influenced by the orientation(s) through which you engage in your work, because the information you will be looking for and recording will be based upon the model of treatment you use. As a reminder, these five major theories will be presented here:


1) Psychodynamic perspectives focus on unconscious factors that motivate behavior with attention given to the events of the early years of life as determinants of later personality development. 

2) Cognitive/behavioral perspectives focus on the role of thinking and belief systems as the root of personal problems, applying learning and reinforcement principles to address problems. 

3) Humanistic perspectives focus creating one’s own destiny by taking personal responsibility for one’s life and finding meaningful life goals. 

4) Transpersonal perspectives focus on the quality of the person-to-person therapeutic relationship believing clients have the capacity for self-direction without active clinician intervention or direction. 

5) Systems perspectives stress the importance of understanding individuals in the context of their surroundings including gender-role socialization, race and culture, family, and other systems. 


As we noted in our third principle above, your clinical records should be designed in a way that aligns with the actual approaches and treatment techniques being utilized. If the primary orientation is a psychodynamic approach, then the design of the treatment plan and the progress notes should be capable of encapsulating what is being attempted in the clinical work and the progress made in line with the defined treatment goals.

However, in accordance with principle number one, it is also important to make sure that the information being recorded is also relevant to the needs of any supplemental treatment provider who may need to be brought into a case should the case move into a more acute stage of problem presentation. Some balances may need to be struck for the provider with a more strictly psychoanalytic/psychodynamic or systems approach in order for the records to fit within the larger medical system.

The practical implications of this principle mean that clinicians have two directions in which they can go. They may select a particular mode or modes of practice and elect to see only those clients who will respond best to that treatment approach while referring all other clients to providers with different skill sets. Or clinicians may develop their skills in multiple modes of practice, allowing for greater flexibility in applying different treatment approaches to different clients, based upon the particular needs that are presented during the treatment process.

Both directions have implications for the design of the clinician’s clinical records. The first direction – the simpler approach – allows the clinician to orient the clinical records towards a format that creates the best fit for the main treatment approach selected. Clinicians who work primarily within a systems based approach would therefore design records templates for assessment forms, treatment plans, and progress notes that best accommodate the kinds of information gathered within a systems model. This means that assessment forms may include tools – like genograms - that are best understood within a systems based model but which may not be included by clinician who work with other clinical orientations.

In contrast to a systems based focus, clinicians operating from a psychodynamic orientation might likewise direct the focus of their records towards the capturing of unconscious material, defenses, resistance and the playing out of the transference relationship. Progress in treatment will be recorded in the successful movement of the client in these particular areas. As with systems based models, principle one should be applied by clinicians who work primarily within a psychodynamic model.

However, in a single model approach, some concessions will still likely need to be made to accommodate principle one, as the treatment records may need to be made available to other providers with different orientations and who may require information that captures different aspects of the clinical picture. Clinical records must seek out to provide some information in the common language of treatment across theoretical lines.

Furthermore, even a clinician who works almost exclusively within a psychodynamic or systems based approach will want to have contained within the record components that gather and examine information about issues related to life and safety, psychosocial stressors, substance use and abuse, medical and medication issues, and other contributors to the overall well being of the client. This is not only concerned with compliance with principle one, but also to remain compliant with some key elements of best practices - and to protect the clinician from liabilities and ethical violations. This applies to all clinicians who work primarily within a single treatment model.

Many clinicians, of course, do not work with a single dominant model, but work more eclectically, picking and choosing techniques and components from a variety of different models and theories of treatment. These clinicians will generally have more complex design needs for their clinical records. The design must allow for the incorporation of whatever information needs to be gathered and recorded within the different models that are brought into treatment. Room may need to be made for both systems based tools and for the kinds of material utilized with psychodynamic models. This is, of course, in addition to the kinds of information needed to comply with principle one.

Once you have formulated a design that finds the best balance between capturing the essential information for your treatment approach(es) and retaining the capability to transfer information successfully to adjunct providers, it is still important to ensure that principle four is followed. There should be a logical coordination between each part of the clinical record and all other parts. If you have an assessment form with a strong emphasis on gathering information based upon a systems approach to counseling, you want to make sure that your treatment plan and progress notes are both designed to record and utilize information within that system based model. 

There is one other important design factor that should be considered here. It must be anticipated that some of your clinical records may possibly be reviewed by your client(s) and/or their attorney(s). This has both clinical and professional implications that should inform some of your decisions about what to include, what to exclude and how to frame certain aspects of what information is recorded and how it is being used.

When a client requests to review his/her record, if there is material recorded that is fundamentally different from what is being addressed session by session in the clinical work, then it can be a confusing experience for the client and can undermine the degree of trust that has been established. If that additional material also contains information that might be perceived by the client as portraying him/her in an unflattering or denigrating light, then there is the potential for psychological harm to occur in ways that are contrary to the ethical purposes of clinical work. We must always be cognizant of this consideration as we decide what we choose to include in the records and the specific choices of how we frame that information.

A client’s attorney will certainly consider whether we have fulfilled our professional obligations in that area. Additionally, an attorney would also scrutinize whether we have put together a case record that is complete, congruent and consistent, operating in accordance with best practice principles.

All of this is to simply clarify that the design of your clinical records should not be done in a perfunctory or poorly considered way. You should give careful thought to the functional purposes for which the records might be used under usual circumstances, but also under the most difficult and urgent circumstances. Your usual purposes will generally support your move towards keeping your records more concise, while your most difficult circumstances will support the tendency to err on the side of comprehensiveness. The best balance will lie somewhere in this intersection between concision and comprehensiveness.

In the next section, the examination of records design will begin with the first form that is entered into the clinical record of the client: the informed consent agreement that is presented to the client at the time of the first session.