)tr,l l- L.r 1 .,.
:r
his r f iic le .x p l o rc s a v r ri -
c r l of l. s a l rn d e rh i c .l
i$ues r c l a rc d to k e c p i D g,
c lir ic nl . e c o rd s .I c .l u ri o rl
r har any o r a l l o frh e i s s u e s
di\cLrsred.nd rbc ofi joDscxprc$ed in
rl ri si ]r r ic lcm iy bec o! e fe (l a Ds.lo v e rn e d
h y r p . r f t ic uhf s r r r e l .rw o r rc g u l a ri o n
rpplic.rblc to N,IF'l!. I s,ill renri.d rhc '
rcederof rhat frct severaltimcsrhroLrgh-
o rrrrhc r r r ic le, bur niy l a i l rre ro d o s o
$ o u l d lor ler d r hc r . .d e r ro c o n c l rd c :
rhr! n., bxrdng sr.rc law or reguhtio! r
e y,!!s Thc . wor ds" c lic n r"x n d " p n r;e n i ' '
a .ft use,l inrerchrngeiblv in rhis article. '
q P.rt II .,f ihis arricle will apl)e.]r in e
: d e \r oJ r his m .s a z n re rn d w i l l
'$ uc
; rdd.ess $rdr issuesas lost, desroycd
: !nd srolrn rccords,acccssro recofdsbv
f t)ricnrs rDd trrents, and dispositionof .
recoels upon rhe dcath of a therapjst. :
-
lli.hrj., l. t $!i{,
Wh y K € e p R ecords?
Aside fron thc frct lhrr ir m.1y bc
.equired, it is sood bLrsintssfr.rftice ro
keet rccords of thc uans.ciidrs rDd
o c c n rre n c es
w i thi n any busi noss.\V i rh
rcspcct to herlth crrc froiessnDs, rhe
nced for sood recorcl keeping is rnore
lmporrart! sincethe Dcrrrl or physical
h c a l rh o frpati enti si l vol ved,asaresi g-
nificint mrrital, fanily, and orher inref-
personrl rehrnnships. SoDretherapisrs
h e v e o p i n ed rhat they kecp mi ni mal
records in order ro prorect thc privacy
of rhe p,tienr. I scnenlly disagrcewith
rh.r approach to record keepins. The
laws oI confidentiaiity end psychorher
apisr-patientprivilcse(rnd horcrc.enr
lx HIIAA)protcci privacy,.s do rhetri
v!cy trrctices of the rherNpist.
(;ood record keeping ls npoftrnr
borh to clientsand ro rheripisrs. Clienrs
j_ir., ,{r:,,!tr} ar}r',!11f,!-.1
lnr) Dccd ro prove rheir m.nrrl status
.rr thar lhey sufferedemorionrl distrcss
or othcr i nrpri netrr.' l h( ncedt o do so
may artre In n custodyorvisirxrion pro-
ceednig,in .r civil lawsuir for damagcs,
in ordcr to qu.lify for reinburremenr,
w orkeri compensrri onor disabili-
' n.
ty case,for a securirycleriance, or for
someorherrcason.C l i enrsdetendupoD
thei. rher.rpistsro keep adcquare .tnrl
rccnrare records,whi.h can help provc,
atnongodrerrhi ngs,drerrheya r e beir g
t| ei ted l or i pi rti cul rr menrald isor def
o. th.t thcy sul d nri rkc. B oodcusk!
di al p.renr. A ddi rl oni 1l l xtri i cr r s f i. ve
i rlglrt to expcct tbrt ll thry were ro
obtri i rrei rmcnr.r. l rrer ti nr e f r , ) nl
inother prrctirioncr, rhtri rhc recoftl\
from drc fri or rhcr.fi sr w (rrl d b . r vr t l
rbl c to the ncw drcrrpi st,i f ncc t leLl.
(nrod recol i keepi rg c.u h elp t hc
thcrrpi sr esr.bl i sh rhrt he/s he. r ct e( l
i pnropri rrcl y i i suedby rhc fxr ler r lol
ncgl i gcnce, (! i f rherc i s i di sc ir lir r r !
trocecd;ngby rhc l i cenri rl gb(,if t lor r n
i l ]vesri gl l ri i )n
by.rn ethi cs con r nr incc.
W hcr i p.ri enrj l rr€nrf r\ orconrnlr ssLr i
ci (l e. hf exnmtl c, or causesp hysicr l
hanl to others,thc drerrpi sti s nor inf r o-
qucntl yrhr i arscrof i n i nvestigr r ioD ol
hrvsui tto (l ctcrri new hcrheror nor t hc
thcrnpist rcicd .rpfrcpriirtely. A mcm-
bcr of. c.,upl .or frmi l y rccei vingscr v
i cesmry try tol rol d rherhcnpi str espoD-
si bl efor I di vorceof s.par:rrionor t o.
dre l.ss of cusrody or visi$tnln rishrs.
V/ell{locDlrerred rccords crn hclp rhe
thcrapi srpr' ovcthdt he or she.rcr ed rs a
rcaylrablI pmdenr pradirnDer of lil(c
licensurewoul.l h:rve.crcd rnder simi-
C onteht of R ecords
Some starc laws or reguhrions specify
the coDtcrt required to be in rccords
m.rinrriDed by Mf-Is and/or othcr
licenred hcahh p..,fessionrls, wb,lc
othff state laws takc a tlifferenr
approachrnd l eaveacru,l conre nr r or he
rl i screti onof thc rherrprsr.C ! lif o. ! r ir
l.w,lir eramplc, sr.resrhar ir is trnpr{)
iessrcDalconducrif !n Ml'Tfails ro keer
rccords consistcnt witb sourd clinicrl
judsnenr, rhc srandardsof rhe prcfes
sion,r.d the Darureofrh. scrvicesbe;ns
,".,.,,.,,,,...,
43
 ,e n der ed.T his k iil o f s r u r€ p fo y ;d e s
ilcxibility for rhe pLactitioner.Marriage
rnd frmily therapv.like the practice of
n tcd ic ine,r s bot h an a rt a n d a s c i e n c e ,.
rn d rheac t ualc ont e n to fa fe c o s h o u l d
helcftrorhr soundcliscrctionoftlrc rhef
i p i st. O bv nNs ly ,r h(ra p i
p r ivirh a sratc hrv or re8ulirion thar '
mrn dt r t r ss pec ilicc o n re n l .
()ne strre law' in speciiytrrg rhe
conrcntol r summary of drc
'nrnd:rrory
.c.ods, sivespri( rionersuseful,rt:or
mrn o n r s io r h( f os s l b l ec o rte ' r!o frh c
fu l l rc c or o1.lhc hw s p e c i fi c srh .rrrh c
i L rn ]nr ar ynr us t c on ti u t rn to rm i n o n
\u (h . s t he c hief c o m p h rrr o r c o n -
5ome
therapists
keeprecords
indefinitelq,
aslonqasstoraoe
does
notbecome "
imaiorp'roblem.
Gene-rallq,
statelaws
donritreruire
destiuttion
ofrecods given
after'a
number
ofgears.
fl .rn i \ , f er t inenihis t o rv ,fi n d n rg sfro n
rnd referrals to othcr
h e rh h c r r c pr r r v r t c r sd, i a s n o s i s(w h c rc
d tr.n nined) , pr ogk ss o f tr.e a tn c rr, .
p ()A.o\ r s ( iD. ludings i s n i fi c .n rc o n ri n , ,
n 1 .s tn) blc Dr sor c oD d l !i o n s ), p c rri n e n r'
rcto ft s oi diignos r i c tro c fd u re s .n d
i e sl \ rnd r ll di\ c hlr se s u mme ri e sa, n d
o b te .r i\ r lur ding!f f om th
H Il, \ A ( ! he" P r iv a c yR u l c " ).rl s o p ro -
!idcs nseful inform.tion rcgarding tLc
co n tc r t oi r c c or ds. J h c re g u l a tn ' r
d e s.ribe\r eeof dsasinc h n rg i re m s N c h
i \ m.d' c r r ion pr es cri p ti o ra n d mo -
rofl ng! counselrngsessronsrarrand stop
ri n cs, r henodaI nies.n d frc q u e n c i eosf
tre :mcr r iur nis hed,rc l rs o f c l i n i c a l
re\r!. r.d anv sum arv of fte ioltorv-
i n q i rrns , diagr os is ,f u n c l i o n a ls ta ru s ,
th e rre r t m enrplan,s vmp ro n s ,p ro s n o -
!,sj rrd progrcss ro dar.. It is always
4 4 r. "' * r , , "- ^ *.^" ^,'" '
inrportant r{) accurately document all
biuingsit1d paymerts so.rs ro avoid fee
dispureswith pArlents-Thc AAMI,T's
Code of Erhics provid€s rhxr MFTS
na intain :ccurate a nd edequ.tc clinical
and tinnncial fecords.
Amons rhe nrost hchful thnrss ih.r
c i n b e d ocumenredarc any consuhn-
tions hid with oihcr fractitidrers who
hrve corfnneil or expresscdsupport
lof rhe rhc.apisfs trcarment aptroich.
Bo rh th e i i cr of thc consul tati on,.nd
tl e s u b s t anceof i r, can ofren h(tp ro
trove thrr the drenpisr w:rs not ncgli-
Se n t.l v e n thoushprofessi onal opnri on
.nd judgnrenr nray (liffcr. dre thcrapisr
mry havc!cted conrpetentlyand appro-
pfirtely, albeit not perfectly. Anothcr
u s e fu l th i ngro documenri s rhefnctthar
rhc therapisrhas referrcd dre parienr to
. p h y s i c i rDf(,f I rnedi calex.m, or to a
psychiatristfor medicarion,or to orher
licensed praclitioners for tcsring or
orher scrvices. Of coune, Nch docu-
mc.trtion only occurs whcn the thera-
tist is firsr rware of rhe needro consutr
or to nakc a referral.
It s h o ul d al so be nored, and nor
v re w e da s inconsi srcnr ro i hc rbove di e
cussrD, !b.r some care and dircreridr
should bcexercisedwirh respccrrocon-
tent. Not cvery detail or every spoker
word needsro be rccorded. Therapisrs
mLrstoitcD bal.ncc colrpeting i,neresis
when derermining record conrcnt.
Somcrimesa ther!pisr may wrntto or!ii
r nane from thc record in orderto pro-
tecr the parient or a rhird party. lf l
prtrcnr w erc hrvrng an extra- nar ir . l
affair, for cxample, the patienr and rhe
dlerapisr misht be nore conforrxbte if
the nane of the prramour ivas ornittcd
fron the recofd.The D rmeofs uch per
son rs trequendy not relerant ro thc
rpproprirre trcrrment of $e patienr.
For H ow Long S houtd
R ecords B e Mai ntatned?
Stirtelxws viry ;n answer ro rhis ques
tion. It seemsas though seven to ren
yerrs is withn the upper.range of the
tnncsspecificd,iftherc istl specification.
Srate laws vary with respcc! ro which
pracritioners.rreaffectedby such a hw.
for exanl e, (rne sutes do not spec;-
ly rhe lengrh of rime thar recofth n1usr
be maintiined by MrTs, but do specify
n ti mefor physi ci nnsor for.,her hhf acil-
i ri es." l n C al i fl )rni ;l ,drere i s no hw
(hrccdyapplicllb le rc M|:fs, physicinns,
LCSIi/s or psychologisrs.Mnny ofrhose
liccntirresfolkrw thc rLrlesapplicrbl€ ro
l i ccnsedhrnl i h frci l i ri es,w hi c h r equir e
dratrccordsbc preservedfori rnnrinrunr
ofsevcnyerrsfol l ow i ngcl i sch . r r ge of t he
S peci alcarc shoul tl be i uk er wir h
respccrto drc rccords of a minor. It is
my b€l i efrhrr rhe rccofdsof a m inor
shoukl be kepr a! Ierst three or more
yerrs aflerrhe minor hasrcachedrhe rge
oi 18 years,ard, i n rny cN se Dor, t ess
rhrn sevenyears(unlessa longer rnne is
spcci fi edi n hw or resul .ti on ) . Som c
therapists keep reco.ds indefinitely, as
long . s srorige doesror bcmme a naior
problen. cenerilly, staic laws do nor
require destrDcrionof records after a
giver nurber of years.
What,s the Oanger of
E arl y D e3tructi on?
Therapistsmustbecarefnlnoi to desrroy
records too sooo, even in statcswhere
there is no law or regulation requiring
thatrccords be kepr fora specifiedpcri-
odof ti me.Thep.ri entc.n$rerndallcse
thrt .rly desrrucrion of rhe records
causedhnn/her darnage.For insi.nce,
Ihe par;ent nislrr he inv(,lved in higa-
tion where thc tlerapistt testimony is
necessary. !-ailure!o prodDcerecordsin
support of rhe rherapisr\ testinony
n L {h r \! . ll lv er k enr hep :rti e n t\to s i l i o . e re l l v d os o enhcrkcruse of. concern
rbout their privacy ard confiderrialitv.
,\n or li. r dr n8erol e i rl v rl e s L rn c ti o n or becrusedrcyareupserwtrhtbe results
r.kr.; r ( i t h. f r t ienas € x fc c ra r;o nrh rt or tlirectior ofthcrapy anclrvant possi
l , r.' lr c r lr hc r r e r e. o tu 1!v s i l l b e .v ri l ' bh' ncgativc cvidcnc suppressed.Nei
'
.rl .l . r, i iLr f t n pr oy id c fso f c .rc , !v h o tIL-rrersol1rsgencrallysufficicnrrorvaf-
n i , rinr nr f r on, r lic rc c o rd o i p ri o r ranr dcsirucrnD or "ftrurnnrs" ot rhe
rk.,rnr . r r . I r c r h. r s r h r fri o f rh .r.r.i s r
J,..,i : , \ . r hc r wis cnn rv i i h b l c . In rl ,rt Own*hip of recotls ofttn becomcs
.,... t hi r ec , , s nr v b c p rrti c u l a rl y rI i s s u ervhcn i n enrpl oyeeor i fde
f. rtr) r r t hc nc x t t hc m p i s t.T h c th c r- p c rl e n tc rn trrctor,:rfrerw orki ngf,,r.n
,:.r,.f , r c nc nt c s r lt rc c o rd s n ra y rl s o !s e n o (.o n l rofi t) or l .,r i n) i n(l i vi cl
-. .: , , ' f n ir r inr . nr n e c o i rh c rc c o s u x l o , e n ti i y,hrves rhee.rtl oyhent v()l
..:.r , t t o*r hLe iLr n rret| e rtrrc n t o f n l l u ri l y o r i s Ii red.l )oesrhc.l ep ti .l j
:.. i .r : , . f r . \ { t ( t iiion .)l l y s, o o rc rrs n c d rc ra p i s tta kc thc fi l cs rvi th hrL?l )ocs
'l r rr r,r l\ J ( \ l|uf t |, r r J c t.rc \ p i rti c n l s rh e i r8 e n cyor othcr cnl i ry kcct i copy
t :l ,cir f lr hr r , r & e c s s rh c i r n rc n trl o f (l re re coftl s?' l ' hernsw ers ro rl )ese
l )..,l i i , r . , i, J s .\ ! 1, , (li., ,y I e s rl ri n r.r) (rre (i o n s dcrefd uron w hcrher rhe
fi ri e rr d .ei dcsn) srxyrr rhe.grn.y (rl x.
I .,, 1r, l( \ r , , , . r in, . i n ,l .l t,{ ,v c t,, h e i .mfl o y .r) rnJ hrvc r ncw tl rcnpi st
t)i ,1 ... r , r , ir lr . r ( , \ r ! rr!. S,rft)()s rh
e e rs s i s n c (lro rhr ci sc. ,n w herh., rhc
rl r,r.rli\ r \ f f ( 1. , f hr \ I .,l n rh l n i l l l tl
' rx i i c n r (l c e i d.sn, l ervc rhe xscf.y i n(l
.rr.rr\r lili\ / hf , ! ! ir l, r l tr l i .ri \i n g b o rftl . e rn ti ru e sto l t sccnby thc {.nrf r| cfr'
l l ,i \ s , n, l( l i( l, x , l( r ( ) rh r 1 \o .f(ti l i h c fi s r i r . rcs' !1ri nA .
rl r',.,t) i\ rl) . r J , lf s r ) y r ,l n ..(n k r y e rr Ir i s i n rportr!rtr) dctc,In c w honr
i t| ro r l, . , . r f \ f n, l. , l . r.,1j rn rL (rr i h e rh c l )i ri .D t prI\ (rhe tn' i l i ns rhcri t,i \t
ri n i .rl r . hi. r f ( lr c r ( iy . ( trr{ )rrt,h i rri l l rs ,)r th c .,.r,l()y.t) bfcr,,s(ofrf,, rhi rrs,i l l
rL t.r. ! n. r hl. il { t ur Lf.h rl ,n s h i r? O r b c rh ( j ' $ s ,nr ,)r..rr! i h.rr" ow ,r\" tl k
1 i r[.rp' t hr t lr r npis t J ts n rv s rc c rrJ s I fc ,n l ts .Il rhf f.rnl rr (l c.i dfi k,.,' )i i n
ri f,,. , ( . lr r , ) lr jr Lhf(rrr { ,)f i n N n ti c i ,( ttu .t,D c rr!!i rh rh. (l cpi rri ng rhfr.-
r.r!,,r r r h. t ur , il hr c ru s t th t d re rrp i rt ti \r, i i i s i D rfofri rr hI rhr rhrr.t]i srn)
\.rrA n, r \ , ir ( l r r s r l) r i n Fi n c o frr. l n )th h rv ..r l e rsr r.ot)y (' l rhr frcofti s s,,
()rrl r. r hit r . \ . f , , . ui, ^ (,rd ,r.d s h o u l db c rh .r rfc rrm tnr i s n,,i i n' tri rtd. l -hr
.u ,,:,i r l hv r er nog, rpo i c y tg ftl i n g rh c c rrp l o y e rshouklkrep rt l ei i t r c,)pyof
rcL rl . r r, 1, . r r, r c r ionoI r e c o .d sw h e Dd ty rh c r.c o r(lsi ft i t i s i nrpoft.nrnrr rhcrn
...rh r lr f J . s r s nr r . d. s c . l h c .g r i s g e n - to hrve (locLrnurrrrrf r)i rhe rrlrttrrnt
f,rl l \ ii. , r ! 1, . r ! 1nir n rl )e d ri c o f .l i s - rl r.r w .rsp rovi dedw hi l e the| rri enr l yrs
.l ,.rr.:., r r r ef lr Ln. r r io nT.h e te rm;ri rri o n ;Dd rc i fc .re .In thr cvenirhrt drcprti ent
l ,,,rc. ' ' l, onl, lht c r r ci u l l vd o c rn n e .te d . wrre ro (lrci.lc ro sr.y rt thc agcncyand
ro s c ea n rt rhcrrhcrapi sr,rhf depl ti .s
\r'r'h oO whs t he Re c o rd s ? th e p i s tu u rLl ortl i nari l ynot recd and
\\'l ).r Lar I e t , r t ieni, n to n fe rm i n rri o n n o r b c e n ri dcdro trkc r .ory of rl rc
,,i rh i r t hr ions hip, rc q rc s rsrh .r rh e records ro his/hcr ncw locxrn,r- \Yere
th d rpi' t Llr s t r ovall t r c rrn re n trc c o rd s ? th e frri e n t r) l rter ransttr frn the
Ii r\e r l\ ent is r is c on s i l e re dto b c th c .gency Lrck ro ihe detaftins dlerrpist,
.$ d rr , ) i t h. r , c or ds ,.s i s $ c c rs e i n I .of'y oi rheigcncl's reco scoul.ithen
n ro sr r ur s . ll. r ions , tl c rl rc ra ti s t w i l l o
rl r l l r c ll t he lar ic n r rh a r rh e re c o rc l s
\ L l ln ,r tbe der r ov edi ,r " l r.m d e do v e r" arcHlaDs.LG.LE,r.o.is an
\\'h rl . p iena of t er rh rv e .e rh ;i ri s h rs AAMFT.on s! kant who
r.rtri d, r s r c c e$ t o d re re c o rd s(e -c ., providesleqalcons!ltatlon
, re rr i, m r nd c or y i n s ), th e y o { ,rl h ' ro AA^4FTCllnlcalMembers.
]r.r\. n . , igl) r r o c on rF l d \e rrp i s tsr.) Toac.e$thisfreeservi.e,
r.\i !r! { ir " f enr . r " . ll re c o .d s V/h . en pleasev sit www aamft.org
trre n r \ m al( c s uc r rr c q u e s rs th
, e y g e n or.onta.t Rlchard at (853)4s6 0695.