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 lawyer to learn more about your rights.  An experienced liability lawyer will be able to address your concerns and give you advice on the proper course of action.