Confidentiality in Therapy: How to Securely Document A Session
Are you just starting out in practice and wondering how exactly to document a session confidentially? Have you been in practice for a while and want to confirm you’re doing it right? Do you have questions about how to record information and maintain privacy while you expand into the new frontier of Telehealth?
Maintaining confidentiality in practice is essential. It’s not just a lovely notion. Securing client privacy is a legal and ethical requirement. Because therapy notes can contain truly sensitive information, they are accompanied by additional protections.
When it comes to therapy notes and confidentiality, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requires:
“… a covered entity to obtain a patient’s authorization prior to a disclosure of psychotherapy notes for any reason, including a disclosure for treatment purposes to a health care provider other than the originator of the notes.”
The only proviso?
“… the Privacy Rule recognizes circumstances arise where health information may need to be shared to ensure the patient receives the best treatment and for other important purposes, such as for the health and safety of the patient or others.”
In short, as a therapist, you are legally required to protect your client’s therapy notes with gusto. Except in special circumstances, you must ask for and receive permission before divulging information to anyone.
The importance of confidentiality (and what this term really means)
If you betray someone’s confidence in your personal life — and they find out — you’ll likely experience consequences. Anger. Disappointment. Distrust. Regret. Even a withering or fracture in the relationship.
It seems obvious, right? Confidentiality is crucial to building and maintaining trust and a healthy relationship.
But in a clinical setting, this term carries greater weight. As a therapist, you are privy to private information; information intentionally not shared with others. With this comes a serious responsibility. You must protect your clients and their information from exposure and harm.
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An article published in the journal, BMJ, described confidentiality in a way I personally like. “The principle of keeping secure and secret from others, information given by or about an individual in the course of a professional relationship.”
In practice, the confidence that accompanies confidentiality will bolster the therapist-client relationship. This will help you achieve better results with your clients and allow your practice to thrive.
Legally, an iron-clad system that protects client confidentiality will also protect you from the long arm of the law. Breaches can not only destroy your relationship with a client, but they can also come with serious legal, licensing, and professional consequences.
How can you ethically document a session with confidentiality in mind?
The first best step is to be explicit. Upfront.
Your clients likely have an understanding of the term “therapist-client relationship” and what it entails in regard to privacy. But they may not understand when confidentiality may (or must) be broken. This is important.
- Speak about this clearly before therapy begins. For example, share that when a client is a threat to themselves or others you may (or must) contact appropriate services.
- Answer any questions. Include this as part of the written consent form that you have your clients sign. In truth, it is part of informed consent.
- Explain how the information you collect during therapy is protected.
- Then make sure you follow your policy.
If you’d like to know more about how to ethically document a session in general, sorry 10 Unbreakable Rules of Therapist Confidentiality is a good read.
The best option: paper versus digital record-keeping
As times have changed, so has the way we track and collate information. Particularly with the more recent shift to telehealth therapy. As a result, the paper versus digital record-keeping question is often asked…
“Which is better: paper or digital?”
We believe if you plan to be in practice for some time to come, digital approaches — including digital record keeping — will become standard. While writing down notes has played an important role in the past, digital technology will (and already is) transform the therapy landscape.
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The cyber-world allows for easier consultation delivery, note-taking, therapy tracking, adjunct support (think apps and automated email delivery), appointment booking and confirmation, and receipt of payments. Digital also removes the need for ample secure physical storage.
Of course, you must make the right decision for your clients and yourself. With that said…
“What remains the same?”
Whichever option you choose — written or digital— there are similar ways to maintain confidentiality. You should:
- Securely lock client notes away
- Implement policies that limit access to strictly those who require it
- When speaking to an authorized person, never do so in a public or insecure place
- Close a file when it’s not in use
- Don’t remove client information from the secure source in which it is held (i.e. do not take notes home or do not save them to a non-secure device or location)
- Keep quiet. Your family, friends, acquaintances, and others should not be privy to what takes place in the consultation room
“What is different?”
While the need for security remains the same, how this is achieved is markedly different.
An article published on Good Therapy said, “Historically, paper notes were kept in a file cabinet with a lock and key. This is no longer the safest way to store your therapy notes and keep them safe. Digital solutions are much more secure.”
This is provided that you use secure systems. For example, HIPAA-compliant software.
Password tip: Always choose an impossible-to-guess string of characters and keep your password protected from disclosure.
How long should you keep client records?
This is a tricky question. For a number of reasons.
Sometimes a client will cease therapy only to return some years later. In this case, holding onto their records would prove useful.
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High-quality records can help prove the rationale for treatment, support billing, and be used as supportive evidence in a court case. They can, in effect, protect you. As you can see, there are a range of important reasons that you might wish to keep your client records.
However, keeping records also raises the risk of a breach of confidentiality. Simply because the records still exist.
Then there may be conflicting federal and state requirements. Requirements that you must know and understand.
So, what should you do?
According to the American Psychological Association (guideline seven):
“In the absence of a superseding requirement, psychologists may consider retaining full records until 7 years after the last date of service delivery for adults or until 3 years after a minor reaches the age of majority, whichever is later.”
Remember, also take into account the risk of a breach, of retaining information that has become obsolete, and the protection or other benefits that may come from record preservation.
How to ethically dispose of therapy records when they’re no longer needed
If you decide to cull records, ensure you do so ethically. No information should be detectable after purging.
According to the US Department of Health & Human Services, no specific disposal method is required. However, the records must be completely and irreversibly destroyed.
For paper records, they suggest burning, pulping, pulverizing, or shredding.
For digital records they suggest clearing, purging, or physical destruction; for example, incineration, melting, pulverizing, or shredding.
The main purpose and responsibility are to destroy the records in a way that ensures information is unidentifiable and unable to be retrieved.
Check with your governing body to ensure you follow best practices.
Confidentiality in therapy is crucial. Both its perception and practice.
Clients and the law require that privacy protection is a priority. That you take significant, strong steps to keep the records you collect safe from prying eyes and ears. Whether accidental or intentional, exposure is unacceptable.
Explain what privacy means to your clients, including when you would be required to breach confidentiality.
Have policies and procedures in place to secure current records, a standard length of time that records are kept (that follows professional guidelines and can be altered to fit specific circumstances), and a plan for the complete destruction of records.
Always remember that documenting sessions with confidentiality in mind is fundamental to therapy and requires great care.
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