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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:

  • The symptoms the patient had when he first arrived at therapy
  • Any prior therapy the patient has undergone
  • Any history of mental illness in the family
  • Any medication the patient is on
  • How long the symptoms have lasted

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:

  • What the patient said
  • The therapist's responses and questions to what the patient said
  • The patient's behavior during the session

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.

Photo of page author Ken LaMance

, LegalMatch Law Library Managing Editor and Attorney at Law

Last Modified: 09-21-2017 02:57 AM PDT

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