Informed Consent
Telehealth Consent
Disposition of Records
Professional Disclosures
Documentation Essentials for Psychotherapists
Mastering Practice Documentation
Documentation in psychotherapy is a fundamental aspect of practice that ensures the integrity, continuity, and quality of care. It involves maintaining accurate and detailed records of client interactions, treatment plans, and progress notes. These records are crucial not only for legal and ethical compliance but also for facilitating effective communication among healthcare providers. Proper documentation supports the therapeutic process, aids in treatment planning, and safeguards both the client and the therapist. In an ever-evolving field, staying informed about documentation standards is essential for maintaining professional excellence and accountability.
Information on this page, and any other pages on the VPA website, is not intended to be a complete description of all requirements and is not intended to be legal advice or guidance. Be sure to consult with an attorney focusing on health care law in your state to ensure your documentation meets all relevants laws, regulations, and codes.
Key Features of Documentation
Comprehensive Record Keeping
Maintain detailed and organized records to support clear communications and compliance.
Confidentiality and Security
Implement robust privacy measures to protect client information and comply with legal standards.
Accurate and Timely Entries
Ensure all documentation is completed promptly and accurately to protect yourself and your client.
Standardized Templates
Utilize standardized forms to streamline documentation and enhance efficiency and consistency across patients.
Informed Consent
Every psychologist should have a well-drafted, complete informed consent document that you provide before initiating services with a client. Your informed consent document will establish upfront expectations, requirements, etc. and can minimize the bases for malpractice suits and ethics or licensing board complaints.
The APA ethics code (section 10.01) requires psychologists to inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality. It also requires that you provide sufficient opportunity for the client/patient to ask questions and receive answers.
If you’re providing therapy involving couples or families, the APA ethics code also requires you to take “reasonable steps” at the outset to clarify which individuals are clients/patients and the relationship the psychologist will have with each person.
TrustPARMA sample informed consent
You must review any samples carefully and make sure your informed consent is tailored to your practice and to Vermont law.
At a minimum, your informed consent document should contain the following:
- Introduction to document and practice
- Disclosure of information
- Services offered
- Evaluation
- Psychotherapy
- Benefits and risks of therapy
- Confidentiality
- Electronic communications
- Fees
- Payment
- Insurance reimbursement
- Client rights
- Telehealth informed consent
- How to get patient records in the event of death, incapacitation, etc.
- Termination of services
- How to contact the therapist
- Patient and psychologist responsibilities
- Statement that patient agrees
- Signed and dated by both you and patient
You might also consider including provisions about:
- Social media
- Legal proceedings
- Third-party consultations
- Appointment cancellation policy
- Medications
Telehealth Consent
You must obtain and document a patient’s oral or written informed consent for the use of teletherapy technology prior to delivering services to the patient. That must include:
- an explanation of the opportunities and limitations of delivering health care services through telemedicine;
- identification to the patient of any other individual who will be participating in or observing the patient’s consultation with you and obtaining the patient’s permission for the participation or observation; and
- assurance that all services you deliver to the patient through teletherapy will be delivered over a secure HIPAA-compliant connection.
For services delivered through teletherapy on an ongoing basis, you need only obtain consent at the first episode of care.
You must include the patient’s written consent in their medical record or document their oral consent in their medical record.
Neither you nor a patient may record a telemedicine session.
The Bi-State Primary Care Association has a sample telehealth informed consent, but you should make sure it is tailored to your practice and to Vermont law. Sample Vermont Telehealth Informed Consent
Professional Disclosures
You must disclose in writing to patients your professional qualifications and experience, including:
(A) all relevant graduate programs attended and all graduate degrees and certificates earned, including the full legal name of the granting institution;
(B) a brief description of any special qualifications and areas of practice;
(C) if providing direct human services in a service or technique that is new to the profession, clear and concise information about the innovative nature of and known risks associated with the services so that the client can exercise freedom of choice concerning such services, which should also be provided to the Board of Psychological Examiners;
(D) a copy of the statutory definitions of unprofessional conduct (3 V.S.A. § 129a and 26 V.S.A. § 3016); and
(E) the process for filing a complaint with, or making a consumer inquiry to, the Director of the Office of Professional Regulation. You can provide this link: File a Complaint
We recommend checking the content of your professional annually to make sure it is current as to your information and the listing of current laws.
Disposition of Records
Vermont psychologists (and other mental health care providers) must have a plan for the “responsible disposition of patient health records in the event [the provider] should become incapacitated or unexpectedly discontinue practice.” 3 V.S.A. § 129a(25). Failure to do so constitutes “unprofessional conduct” under Vermont law and could result in penalties or sanctions.
Vermont law goes a bit beyond the idea of a “professional will” in that it requires a plan in the case of events other than the practitioner’s death, but the general idea is the same.
Similarly, the APA ethics code requires psychologists to “make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists’ withdrawal from positions or practice” and to “make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted….” APA Code of Ethics § 6.02(c).
Examples of specific instructions to include in Professional Will:
- Instructions about how you want current and past clients notified of death/incapacity.
- Prompt notice to professional liability carrier and the Vermont Board of Psychological Examiners.
- Arrangements for clients to get their records or copies of their records to their new health professional, upon consent.
- Directions for what happens with all remaining records.
APA Professional Will Guidance & Supplement
You should consider maintaining some information for your professional executor (or the person who will transfer and protect the confidentiality of your client records). Examples of the information you might want to maintain include:
- Names and contact information for individuals who may be able to assist in locating/accessing client records and other relevant professional documents (for example, colleagues, office staff, family)
- How to access current client records
- How to access past client records
- How to access billing and financial records
- How to access my appointment book/calendar and client contact information
- Location of electronic devices used for psychology practice
- Passwords for computer and other electronic devices used for psychology practice
- E-mail and website addresses
- Office phone number and voicemail access code
- How to access my professional liability insurance policy
- Location of any necessary keys for access to my office, filing cabinets, storage facilities, etc.
The legal issues around client records and their disposition are complex, highly fact-specific, and require legal expertise that cannot be provided by VPA. In addition, laws change over time and vary by state/jurisdiction. The information herein should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.
FAQ
Are there documentation considerations outside my patient communications?
1. Use of the Title “Psychologist”
Psychologists must indicate their complete title (e.g., psychologist-doctorate or psychologist-master) on all signs, business cards, letterhead, advertisements, etc.
2. Name & Address Changes
Psychologists must notify the Office of Professional regulation within 30 days of a change to their name or mailing address. Failing to do so is defined as “unprofessional conduct” by Vermont law (3 V.S.A. § 129a(a)(14)). You can update your information on OPR’s online services platform.
3. Plan for Disposition of Records
All psychologists must have a plan for disposition of their patient records in the event of their sudden death or incapacitation. Vermont law consideres the failure to have such a plan to be “unprofessional conduct” (3 V.S.A. § 129a(a)(25)). The APA Ethical Principles of Psychologists and Code of Conduct similarly requires psychologists to “make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists’ withdrawal from positions or practice” and to “make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted. . . .”
4. Continuing Education Records
Most states require you to keep your continuing education records for a period of time. Vermont requires that you keep them for four years, but other states may require a longer retention time.
How long should psychotherapy records be retained?
Record retention policies vary by state, but Vermont law requires you keep your psychotherapy records for at least seven years after the last client interaction (or after the individual turns 18, if a minor at the time of the last client interaction) and for 10 years if the client is covered under a Medicare Advantage plan. VPA recommends keeping all client records for 10 years for simplicity and ease of administration.
How can I ensure my documentation is compliant with legal standards?
To ensure compliance, familiarize yourself with relevant laws and regulations, such as HIPAA and the APA and ASPPB ethics codes. The best way to ensure documentation is compliant with legal standards is to have it drafted or reviewed by an attorney whose focus is on health care law in the state in which you practice.