Record Keeping and Documentation for Mental Health Professionals

Good records are key to good care and good business.

Good records capture – in real time – our observations, as well as our professional opinions and client related exchanges and events. They allow us to plan the best possible clinical work with clients, and to help us reflect on professional practices and decisions.

Our records can:

create evidence of our therapeutic process and procedural systems (such as billing and scheduling);
support openness and transparency;
help us protect ourselves from intentional or unintentional altered facts; and,
ensure the clean and accurate transfer of information if the need arises for continuity of care.

Comprehensive and accurate records are important, because they help to create transparency, support us with ethical and legal obligations to human rights, and help us defend ourselves in cases of liable, lawsuits, or tax audit. They are legal documents that may be accessed and used by different third parties and legal authorities.

Effective records put us in a good position to manage issues that might come up with clients and regulatory bodies. While good records cannot stop a complaint from being filed, they can demonstrate the ways we act in good faith and in the best interests of the client.

New online course supports good record keeping

The OAMHP now offers a self-directed online record keeping course specifically designed for mental health professionals.

Developed in-house with input from regulatory colleges, the comprehensive course covers requirements and standards of practice from government regulators and regulatory colleges. It includes:

The purpose of record keeping,
The essential components of clinical records,
How to meet the privacy requirements of PIPEDA,
Handling access to and disclosure of records.

There is an optional free module for supervisors to help them understand how to document clinical supervision.

Attendees earn five Continuing Education Credits (CECs).

Cost:

OAMHP Members: $150.00+HST

Non-members: $200.00+HST