[(JD)]

I hope it helps... and it isn't etched in steel... but a guideline of information....

There seems to be, at times, misunderstandings regarding a psychologist's patient's files/records.

File: This information is kept on each patient; it includes such things as name, address, contact information, and other information relevant to the type of psychological services being provided, such as diagnosis codes, and expected duration of treatment. It is often accessible by the office secretary etc, who needs to access it for billing insurance companies etc. It is the briefest of records and does not contain session to session discussion information. It is usually kept in a file room, in a filing cabinet, under lock and key. It is the patient's responsiblity to view this periodically to make sure it is all accurate and up to date information.

Record: Many use the term process/progress notes to mean the information that is only accessible by your psychologist. This information is gathered as part of the assessment, diagnosis and treatment of the patient's condition. This information is retained in order to document what happens during sessions and enables the psychologist to provide relevant, informed, psychological services. It is seen only by the psychologist. These notes, if known to be kept, can be subpoenaed by court. The information kept is usually minimal, to keep confidentiality, but broad enough to allow continuity of services.

You are in the sessions, so there is no need to view this information. However, your psychologist will discuss your questions that you have about the information contained within this record. Much of the terminology contained within this is on a professional level and easily misconstrued by the layman, imo.

Notes: These are often the personal notes of a psychologist, made to remind him/her self of questions or actions needing to be answered or asked or made on a detailed level. They might also contain challenges that the psychologist makes to him/her self about the course of therapeutic intervention on behalf of the patient. This is private, kept, seen, and owned by the psychologist. Your psychologist cannot demand to see your journal notes, neither can you demand to know if he/she has any personal notes about your treatment of care. These notes do not exist within the framework of legal issues, nor does any psychologist I know acknowledge that they keep such notes.

How a psychologist determines what records he/she will keep and how detailed is completely up to him/her, with regard to the minimum jurisdiction requirements, or the organizational requirements where they work.

Record keeping under the new ethics code: http://www.apa.org/monitor/feb05/ethics.html

Record keeping pratices: http://www.apa.org/practice/recordkeeping.pdf (Guidelines.)

which country does this apply to sky?

there are people from all over...

Sky, that's very helpful, particularly about the notes. I had never thought about the psychologist writing notes to him/herself about the therapy process itself.

Thank you!