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.
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:
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:
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.
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.
Last Modified: 09-21-2017 02:57 AM PDTLaw Library Disclaimer
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