This law note reviews legal issues specifically germane to social workers' clinical notes or "psychotherapy notes." However, a discussion of clinical notes takes place under various categories of guiding principles, including the NASW Code of Ethics, state medical records acts, social work licensing laws, specific federal and state psychotherapy privacy protection statutes, and state regulations applicable to social work case records in general. The definition and even the existence of clinical notes as distinct from medical or case records has been a matter of some disagreement among states, while recently issued federal regulations recognize psychotherapy notes as a distinct part of the mental health record accorded special privacy protection.
This law note reviews legal opinions, statutory and regulatory language, and ethical principles that control the creation, handling, protection, and release of clinical notes within social work practice. It provides guideposts for professional practice, but does not aim to resolve particular legal problems. Consultation with an attorney, a social work licensing board representative, and other mental health professionals is necessary to resolve particular issues related to clinical notes.
The legal precedent and statutory support discussed in detail in this law note should cement social workers' understanding that it is essential to maintain accurate and timely clinical notes. Clinical notes facilitate the delivery of mental health services, ensure continuity of care, protect clients' privacy, and ensure reasonable future access to client treatment history. Contemporaneous clinical notes are an important part of the client record, as are evaluations, treatment plans, prognoses, collateral contacts, contact dates, and payment plans. Clinical notes often contain the most private client information as well as the therapist's observations, clinical concerns, and relevant anecdotal information.
Social workers sometimes hold the view that the obligation to keep such records is a discretionary one. Although discretion is required when determining what to include and how to phrase comments, this law note provides abundant support for the proposition that clinical notes are necessary to create an accurate treatment record and demonstrate commitment to professional practice standards.