RECORD KEEPING

Record keeping is an integral part of Play Therapy practice. The term ‘records’ includes:

• written records;

• photographs, slides, and other images;

• microform (i.e. fiche / film);

• audio and video tapes, cassettes, CD-ROM;

• e-mails;

• digital records;

• computerised records.

Telephone communications with or about the client should be recorded in the notes. Records should not include abbreviations, jargon, irrelevant speculation, and offensive statements. A clear record of all therapy sessions, and communications with clients or about the client, must be maintained for:

• continuity of treatment;

• clarity of thinking;

• analysis of process and content;

• presentation for supervision;

• communication with colleagues;

• clarity in the case of litigation.

The Access to Health Records Act 1990 gives clients the right to access manual health records made after the 1st November 1991.

The Data Protection Act 1984 gives clients access to computer held records. It also regulates the storage and protection of client information held on computer.

In some cases, information can be withheld from a client. Further information can be found in Guide to the Access to Health Records Act 1990 published by Government Health Departments.

Play therapists working within organisations must establish under which circumstances other professionals will have access to play therapy notes. All records may be requested for inspection if any of the exclusions to confidentiality are activated.

Guidelines for the retention of records can depend on current legislation and health and social work agencies policy statements. As a guide, records should be kept for six years after the termination of therapy.
In the case of a minor, notes should be retained until the clients 25th birthday or 26th if the young person was 17 at conclusion of treatment, or 8 years after last entry in the record, if longer, or 8 years after death if death occurred before 18th birthday.

Notes and artefacts must be destroyed in confidential conditions.

All systems for recording client work must ensure security in order to preserve confidentiality.

Private practitioners must ensure that provision for secure arrangements for storage or destruction of notes are made in case they should become incapacitated unexpectedly or die.