It's important to give a lot of consideration to your clients' records when starting a therapy private practice. These are the records that your clients fill in when they begin to seek help from you, and you'll also make notes on each session after it concludes. While it may seem as though there are other pressing details that should command your attention — namely, marketing yourself and beginning to build a roster of regular clients — there are also several things that you should do concerning these records. Here are some tips for doing so correctly.
Use A Proper Template
Don't make the mistake of drafting up your own client record form for people to fill out when they first start to see you professionally. By doing so, it's possible that you could leave out something critical, which could be problematic should you ever face an audit from your state's therapy licensing board. It's a better idea to use a proper template that the board approves. Generally, you can find this information online, but a phone inquiry can alternatively be useful.
Don't Skip Them
If a client appears to be in some type of crisis and is visiting you for the first time, you may be anxious to begin talking to him or her. It's also possible that the client could pressure you into sitting down and listening to his or her problems. You should never skip the process of having a first-time client fill out his client record form, however. Similarly, if you're busy with a series of clients back to back, you should always allow time for making notes to go with the client's form. Don't ever allow yourself to get so busy that you don't give these forms the attention that they deserve.
Store Them Securely
Your client records will contain a wealth of private and sensitive information about those who entrust you with their care. You need to be vigilant about keeping these records secure. Normally, you can do so in a locking filing cabinet. Make sure that you don't leave the key in the cabinet lock, especially if it's located in your treatment room and you sometimes leave clients unattended in this space. Even if a client hasn't been to see you in a long time, you must still make a point of keeping his or her record safe to avoid breaching the client's confidentiality.