With regard only for the recordkeeping issue right now (I'm in a hurry; more later . . .): (1) Patient concerns about note-taking and privacy are, of course, very common. The best approach almost always involves NOT giving in to their (often superficial) demands, but rather (a) talking a bit about your note-taking and record procedures and the reasons for them, (b) talking a bit about the reasons -- reasonable or unreasonable -- for the patient's concerns, (c) being clinically complete but not voyeuristic in one's notes and other documentation, and (d) allowing time for the patient to develop comfort and trust with your treatment style. If treatment doesn't proceed as well as hoped, it is almost certainly not because of the way you take notes. (2) From both clinical and legalistic viewpoints, I strongly suggest you not significantly modify the way you take notes or document in the record, or allow the patient to unreasonably dictate documentation procedures. (Similarly, would you engage in an inferior or dangerous treatment just because the patient demanded it? Or would you refuse and try to discuss the issues with the patient?) (3) Although there may be an administrative separation of clinic notes and personal therapy notes, the law does not generally distinguish between them. If you or the clinic is sued or there is some other litigation-related demand for the records, it is very likely that you will have to divulge the personal notes. Some therapists don't take personal notes for just that reason; I think that's shortsighted and can be grounds for malpractice in some cases. Further, it is generally far easier to defend accurate and complete notes in a lawsuit than to try to explain why you didn't document things completely. (Sounds a little counter-intuitive, I know, but it's absolutely true. I've worked with many cases in which the usual simple "No SI/HI" was no help at all when what was needed was an explanation of how the clinician was thinking, assessing, and deciding about patient risk.)
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