Adventures in Clinical Record Keeping

Get it on your Kindle for just $4.99!

Clinical notes play an important role in providing quality care and in maintaining the integrity of the therapeutic relationship. Many clinicians request guidance in how to write accurate, clear, structured notes that support understanding of the client’s therapeutic progress.

Therapist 2 Go to the rescue!

This book provides answers to many of the most asked questions about progress notes, and some you never thought to ask! Adventures in Clinical Record Keeping will teach you:

 

  • The “proper” way to take notes
  • What information your notes must contain
  • How and when you can properly edit/revise notes
  • When do you quote, and when do you paraphrase?
  • A step-by-step walkthrough of the note-taking process for client sessions
  • A handy checklist of things remember in every session
  • How to store your clinical notes
  • How to protect the privacy of client records
  • What to do if your clinical notes are subpoenaed
  • How to handle disclosure to auditors and evaluators
  • What to do if the client requests to view his or her records
  • How you protect clinical notes for co-clients in couple, family, or group therapy
  • What to do if an insurance company wants to review your notes
  • AND MANY MORE!

If you need the forms to write your clinical notes on, try our Client Progress Notes forms!

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About Therapist 2 Go

At Therapist 2 Go we create organization and information management tools for psychotherapists that are straightforward and easy to use. We believe that forms do not have to be complicated to be functional and efficient and to capture the client information that you need to provide effective therapeutic treatment. Our goal is to help you run an efficient, profitable business, allowing you to spend more time focused on the therapeutic process and less time on routine administrative tasks.