Record keeping: Commentary on Furlong (2013), Mills (2012), and Bemister and Dobson (2011, 2012).

Abstract

I understand that for many clinical psychologists or psychoanalysts, adhering to the regulations imposed by a regulatory body may result in certain disadvantages or lead them to feel a loss of autonomy. Otherwise, the rights of the clients regarding their files improve as years go by. This text is a reflexion after reading the excellent articles about the record keeping subject.Keywords: confidentiality, record keeping, professional autonomy, clinical practice, ethicsMany thoughts come to mind in reading Furlong (2013); Mills (2012), and Bemister and Dobson (2011, 2012). However, for the sake of space, this commentary will be limited to record keeping and professional autonomy.Regarding the issue of personal autonomy, I have serious reservations about claims that being subject to record-keeping regulations results in a loss of autonomy. In this regard, one must consider the context in which all psychologists exercise their profession. Indeed, psychologists are granted a number of privileges when they exercise their profession. As all other professionals, psychologists who choose to be licensed by a regulatory body, with the advantages that entails, agree to adhere to certain rules or regulations.We could not be granted the privilege of practicing a profession without, in return, accepting its responsibilities. Indeed, we must not lose sight of the fact that the obligations imposed by regulatory bodies on their members are accepted by the members upon joining that regulatory body. That there are many different approaches to psychology does not absolve individual psychologists from adhering to the codes and regulations related to practice. In Quebec, psychologists are held to articles in their code of ethics as well as to those in the Code des Professions (Gouvernement du Quebec, 2012). Several provisions pertain to the clients' right to access his or her file and, if necessary, the right to request corrections to its contents. The Code of Ethics as well as the Code des Professions also contain provisions about the confidentiality of the psychologists' case notes and their contents.In 1992, the Ordre des psychologues du Quebec (OPQ) adopted the Regulation respecting the keeping of records and consulting rooms by psychologists, hereinafter referred to as the Regulation. The Order also published A Guide to Record Keeping, which was last updated in September 2008. Although these regulations and guidelines define certain aspects of clinical practice in psychology, psychologists can exercise their independent professional judgment in the selection and implementation of clinical interventions and document these by using the language of their preferred theoretical orientation in their case notes, all of this within a framework they freely accepted, that of their regulatory body. In other words, professionals can exercise their judgment autonomously but within the ethical guidelines of public order prescribed by the regulatory body.Regarding the contents of the psychological file, I believe that it should contain nominative information, the reasons for consultation, the anamnesis (medical history), and the treatment plan, all of which should be clearly stated at the beginning of the file. The psychologist's file should also contain concise progress notes. Written after each session, these notes should describe the client's state, the topics discussed during the meeting, and the psychologist's interventions. This should be a polished note, devoid of raw data.This method of record keeping should be equally applicable to consultations in independent practice as to those in the public system. However, in the latter case, the psychologists' progress notes should be limited to information that is pertinent to his or her mandate as other professionals will likely have access to the client's file. In addition, psychologists must exclude from the file any raw data that is not interpreted, because, as per the provision in the Code of Ethics, it can only be interpreted by another psychologist. …