All therapists need to keep accurate, up-to-date records in their office. Records are important in coordinating care and referring and terminating patients. Accurate records can also protect you in case of patient disputes and malpractice accusations.
Keep in mind that no matter if they’re paper or electronic, all your records must comply with HIPAA regulations and state laws. Keep physical records in locked cabinets and take precautions (such as virus software) to protect digital records.
If you’re just starting out in private practice, here are 10 documents you should keep when treating new or existing patients.
1. Welcome letter.
Before you hand patients a stack of forms to fill out, it’s nice to include a letter welcoming them to your practice. This letter can include:
- Info about your background and methodology.
- Scope of treatment sessions (time, cost, and cancellation policy).
- Your social media policy (that you don’t “friend” clients on Facebook, for example).
- How patients should get in touch with you outside of sessions.
- Reassurance that treatment is confidential.
- A statement about when you might break confidentiality (such as if a patient says they’re going to harm a family member).
2. Psych evaluation form.
Before beginning treatment, it’s helpful to understand a patient’s psychological background and why they’re seeking help. The psych evaluation form can ask the patient to list general info (name, address), emergency contact info, current symptoms, suicide risk, and treatment history. Check boxes and rating scales make it quicker and easier for patients to fill in info.
3. Medical history.
Physical disorders can have a profound effect on mental ones. You’ll want to gather patients’ medical history to know if they have any physical illnesses, have had any surgeries, or are taking any medications. This form can be combined with the psychological evaluation form.
4. HIPAA notices.
HIPAA notices inform patients of their rights to privacy with regards to their health information. The notice tells patients how they can access info and how their medical info may be used. The US Department of Health and Human Services offers extensive guidelines on how professionals can comply with HIPAA.
5. Consent to treatment.
Patients should agree to receive treatment from you before you begin. They should acknowledge they understand the risks, benefits, and alternatives to treatment, and that it’s not a guarantee for overcoming any issues. The consent to treatment form can be included in your welcome letter.
6. Credit card authorization.
Credit card authorizations allow you to charge patients and grant you permission to process transactions. This document is particularly important if a patient disputes a charge later. The form should ask the patient to state their name, contact info, and credit card data and require a signature.
7. Payment receipts.
Whether you charge patients electronically or they hand you a check, give them a receipt for payment and keep one for yourself. Patients might need receipts to get reimbursement from an insurer or HSA. And you’ll need receipts for accounting purposes and tax records.
8. Document of service.
Keep track of each session with a patient. Note the duration, treatment modality you used, and a general assessment of how the client is functioning. For privacy reasons, keep any notes you take during the treatment sessions separate from the document of service."
9. Handouts about disorders and community resources.
Keep handy resources clients can reference when they leave sessions with you. For example, have prepared handouts about common disorders and helpful books or websites. A list of community resources and support groups can give patients ways to connect with others who share their issues.
10. Termination letter.
Treatment doesn’t last forever. When you’re complete in your work with a client, whether because they’ve overcome their issues or they’ve decided to end their sessions, it’s important to sign a termination letter. The letter can state when treatment began and ended, the diagnosis, the reason for ending treatment, and any recommendations for moving forward.
Many new and aspiring therapists come to the Wellness Institute because they’re looking to get started in private practice. With our program, you’ll also gain access to a robust community of experienced practitioners who can advise you on all aspects of running a private practice. Our Six-Day Training program is a great way to get started with hypnotherapy. And our web guide provides tons of advice on marketing for therapists.