What's in the File? Opening the Drawer on Clinical Record Keeping in Psychology

Abstract

Record keeping is a legally required and yet rarely researched aspect of the practice of psychologists. The current study aims to establish an overview of the record‐keeping practices of private practitioners. Seventeen psychologists employed in private practice settings were interviewed about their record‐keeping practices. Psychologists were asked about the content and utility of their clinical records, training, knowledge of legislation, and their concerns about record‐keeping practices. Psychologists also reviewed one of their clinical files and reported on the contents. Thematic analysis of interview transcripts was conducted with the following themes arising: accuracy, accountability, utility of records, compliance with legal and professional standards, opinion versus fact, and time. The limitations of the current study are acknowledged, and recommendations for further research are outlined.

Key words:

• clinical records
• clinical/counselling psychology
• psychology practice
• psychology training
• record keeping
• standards