Therapist's Failure To Properly Document Patient

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What Must a Therapist Document when Meeting with a Patient?

A therapist must document both the patient's history and what takes place during therapy sessions.  Failure to properly record either of these two things can make a therapist liable for malpractice. 

What Does a Therapist Have to Include in a Patient's History?

The main reason for taking the patient's history is to give context for a correct diagnosis.  Taking a history is important not only for the therapist, but also for any future licensing boards or expert witnesses who may need to see if a therapist acted with proper care.  Most importantly, though, a patient's history is essential for a therapist to ensure a proper diagnosis.  Failing to take a proper history shows a lack of care and can make a therapist liable for malpractice.  In the history, a therapist should include:

What Does a Therapist Have to Do to Take Proper Notes?

Obviously, a therapist is not expected to create a precise transcription of a therapy session.  However, a therapist does have the duty to properly record a general picture of what went on during the session.  While the notes do not have to be in plain English, they do have to be legible and decipherable.  Generally, a therapist's notes should include:

If a Patient Request that his Therapist Not Take Notes, Can the Therapist Choose to Do So?

No, a therapist should never give in to a patient's request that he not take notes.  Such a request will not excuse the therapist from liability for malpractice and may make it difficult for him to make a proper diagnosis.   

Should I Contact a Lawyer about My Documentation Issues?

If you believe that your therapist has been giving you inadequate care because of his failure to properly document sessions, or if you are a therapist who has been remiss in your documentation duties, you may want to speak with a malpractice lawyer to learn more about your rights.  An experienced malpractice lawyer will be able to address your concerns and give you advice on the proper course of action.

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Last Modified: 08-03-2012 12:26 PM PDT

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