Table of Contents

Introduction. Purposes of Clinical Records. Documenting Informed Consent. Characteristics and Contents of Good Records. Confidentiality in an Electronic Age. Exceptions to Confidentiality. Developing Policies and Procedures for Protecting Confidentiality and Managing its Exceptions in an Electronic Era. Boundary Challenges: Impact of Electronic Communication on the Therapeutic Relationship. Retaining and Destroying Inactive Records. Using Patients' Records as Therapeutic Tools. Clinical Supervision Records. Teaching Record Keeping. Psychotherapists and Records in the Legal System. Planning for Interruptions or Closure of Psychotherapy Practices. Epilogue. Appendix A: Sample Client/Patient Information. Appendix B: Sample Treatment Plan Form. Appendix C: Sample Revised Treatment Plan Form. Appendix D: Sample Closing Summary Form. Appendix E: Sample Consent for Treatment of Minor Child Form. Appendix F: Sample Authorization for Release of Information Form. Appendix G: Sample Clinical Supervision Contract. Appendix H: Sample Informed Consent Statement for Mental Health Evaluation in a Personal Injury Case. Appendix I: Sample Letter from a Psychotherapist to a Judge in a Child Custody Case. Appendix J: List of Selected Professional Organizations and their Web Sites. Appendix K: Contents of Accompanying CD.

About the Author

Ellen T. Luepker, MSW, BCD, is a licensed psychologist and clinical social worker in private practice, and an instructor in the University of Minnesota School of Medicine, Department of Psychiatry. She provides training to mental health professionals nationally and abroad on ethical issues and consultation to regulatory boards and attorneys regarding malpractice cases. She was honored by the National Academy of Practice as a Distinguished Practitioner, by the National Association of Social Workers as a Social Work Pioneer, and received Smith College’s Day-Garrett Award for her contributions to professional standards in mental health care.

Reviews

"This book is a lively, reader-friendly compendium of essential knowledge for every clinician that provides specific advice and examples of clinical records while illuminating a wide spectrum of legal, ethical and complex clinical issues." - Judith Wallerstein, author of The Unexpected Legacy of Divorce"Within an ethical and most professional framework.this book assists therapists in meeting regulations for record keeping while at the same time assuring ways to protect the client. It will become an important resource for psychotherapists." - Florence Lieberman, Hunter College School of Social Work, New York, USA"Rooted in 30 years of experience with patients, Ellen Luepker provides detailed practical guidelines and especially wonderful examples of how to keep written records that actually improve therapy and meet the requirements of the legal system. Practicing therapists will find [this] detailed guide to be one of the most useful books they read all year." - Thomas T. Frantz, University at Buffalo, New York, USA"Ellen Luepker has finally made practical common sense out of the thicket of clinical, ethical, and legal requirements for record-keeping. With HIPAA implementation just around the corner, this should be on the 'must read' list of every practitioner!" - Hubert H. Humphrey III, J.D., former Minnesota Attorney General"Record Keeping in Psychotherapy and Counseling... is organized into eleven chapters that cover informed consent, record keeping, confidentiality, handling of inactive records, clinical supervision records, dealing with the legal system, and planning for interruptions or closures of a psychotherapy practice. The structure of the book is logical, and chapter transitions are natural and easy to follow. The chapters themselves also are well organized, usually beginning with a statement of the chapter's purpose or a brief illustrative vignette. The style of writing is clear but not dry, with simple sentence structure and minimal jargon... Practitioners of any kind of psychotherapy would be likely to find this book useful." - Aviel Goodman, PSA Today

“Ellen Luepker gives her readers the best of both worlds – a masterful synthesis of contemporary regulatory requirements grounded in clinical sensitivity and wisdom.” - Jon G. Allen, PhD, senior staff psychologist, The Menninger Clinic; professor, Baylor College of Medicine, Texas, USA“I have used the first edition for years to teach therapists and case managers the basics of good record keeping, and this new edition updates and adds depth…The chapter on ‘Teaching Record Keeping’ should be required reading for every social work and counseling school in the country. This is must reading for anyone who is called to court to testify or who wishes to become an expert witness or develop a forensic practice.” - R. Keith Myers, LICSW, vice president, Clinical and Training Services, Wellspring Family Services; affiliate faculty, University of Washington School of Social Work, USA “Ellen Luepker’s work provides a remarkably complete and readable volume on the current processes concerned with clinical record-keeping and confidentiality. Whether a student, teacher or clinician, this book is a must-have resource for practice information.” - Barbara Berger, PhD, Institute for Clinical Social Work, Illinois, USA“Within an ethical and most professional framework…this book assists therapists in meeting regulations for record keeping while at the same time assuring ways to protect the client. It will become an important resource for psychotherapists.” - Florence Lieberman, DSW, professor emerita, Hunter College School of Social Work, USA“Rooted in 30 years of experience with patients, Ellen Luepker provides detailed practical guidelines and especially wonderful examples of how to keep written records that actually improve therapy and meet the requirements of the legal system. Practicing therapists will find [this] detailed guide to be one of the most useful books they read all year.” - Thomas T. Frantz, PhD, professor of Counseling Psychology, University at Buffalo, USA“Ellen Luepker has finally made practical common sense out of the thicket of clinical, ethical, and legal requirements for record-keeping. For HIPAA implementation, this should be on the ‘must read’ list of every practitioner!” - Hubert H. Humphrey III, JD, former Minnesota Attorney General“Luepker’s book comprehensively and competently addresses an urgent need in contemporary mental health practice, and deserves a place in the libraries of community mental health practitioners, clinicians in private practice, social work educators and professionals from related fields of practice.” - Lana Sue I. Ka’opua, PhD, associate professor, Cancer Prevention and Control Program, University of Hawaii Cancer Center, USA"Record Keeping in Psychotherapy and Counseling was an invaluable resource to me as I launched a private practice. The success of this book is due to Ellen Luepker's dedication to ethical standards in patient care, coupled with her devotion to providing the highest level of clinical care. Ellen's book provides an opportunity for new and seasoned therapists to learn how to address challenging situations." - Kate Cosgriff, Water’s Edge Psychotherapy, Ltd. "This book deserves a place next to the DSM on every therapist’s reference shelf, the shelves of therapists of other treatment professions as well as those of social work clinicians. There are interesting case examples, and much of the text is written in easy-to-read conversational language. [It is] a 306-page, tightly packaged reference tome. The information is detailed and covers every area for which appropriate and adequate record-keeping is essential. Always with record-keeping as context, this work offers a richness of guidance and information in every area of treatment...a fascinating and credible resource for currently practicing psychotherapists. Using the typical on-line protocol for scoring the value of an item – one to five stars - I give this book a resounding ***** assessment." - Inge Oppenheimer, LCSW, BCD, American Association of Psychoanalysis in Clinical Social Work Newsletter
Praise for the Previous Edition
“This book is a lively, reader-friendly compendium of essential knowledge for every clinician that provides specific advice and examples of clinical records while illuminating a wide spectrum of legal, ethical and complex clinical issues.” - Judith Wallerstein, PhD, author, The Unexpected Legacy of Divorce