Documentation and Record Keeping in Psychotherapy
Key Ethical and Legal Requirements
- Speaker:
- Kathryn Krase, PhD, JD, MSW
- Duration:
- 3 Hours 18 Minutes
- Format:
- Audio and Video
- Copyright:
-
Nov 21, 2025
- Product Code:
- POS150409
- Media Type:
- Digital Seminar
Description
- Six step framework for protecting yourself from legal and ethical liability
- Clear, practical guidance on handling real world documentation dilemmas
- The latest codes and laws on record keeping
No one becomes a therapist to stress over SOAP notes – but here you are, still finishing them at 10 p.m.
Because documentation and recordkeeping are essential for protecting your clients, your licenses, and your practice.
But let’s be honest, you probably didn’t receive much training on how to do it right. Not in grad school. Likely not in supervision.
So you can end up second-guessing what to include, worrying about missing important details …
… and often spending a lot of time trying to get it all right – even if it means taking extra time on your evenings and weekends.
And today, it’s more complicated than ever before with electronic health records, AI, client record requests, and evolving privacy laws.
That’s why you need this training.
Watch ethics and legal expert Dr. Kathryn Krase, JD, MSW, a licensed social worker and practicing attorney, as she shares her knowledge of the clinical and legal sides of documentation challenges inside and out.
She’ll show you everything you need to create clear, ethical, and defensible clinical documentation PLUS best practices for recordkeeping, managing digital communication, client access, and more.
From writing effective progress notes and managing client record requests to handling teletherapy documentation and navigating termination and fair information practices …
… you’ll leave this program feeling more prepared than ever before.
So you can stop stressing over your notes and start focusing on what matters – your clients.
Don’t wait. Purchase now!
Credit
Handouts/Brochure
| File type | File name | Number of pages | |
|---|---|---|---|
| Manual - Documentation and Record Keeping in Psychotherapy (9 MB) | 33 Pages | Available after Purchase | |
| Manual - Documentation and Record Keeping in Psychotherapy - French (9 MB) | 33 Pages | Available after Purchase | |
| Manual - Documentation and Record Keeping in Psychotherapy - Italian (9 MB) | 33 Pages | Available after Purchase | |
| Manual - Documentation and Record Keeping in Psychotherapy - German (9 MB) | 33 Pages | Available after Purchase | |
| Manual - Documentation and Record Keeping in Psychotherapy - Spanish (9 MB) | 33 Pages | Available after Purchase |
Speaker
Kathryn Krase, PhD, JD, MSW Related seminars and products
Kathryn Krase, PhD, JD, MSW, principal consultant with Krase Consultant, is a lawyer, social worker, and expert on the legal and ethical implications of professional practice. She has over two decades of experience as a professor of social work in undergraduate, masters level and doctoral level social work programs. She has authored multiple books and articles on the subject of professional ethics, including Making the Tough Call: A Resource for Professional Reporters of Suspected Child Maltreatment.
Dr. Krase blogs regularly on topics such as professional boundaries for clinicians, confidentiality in practice, and racial justice in mental health practice. She has years of experience consulting with government and community-based organizations to develop policy & practice standards, and trains thousands of mental and physical health professionals a year on various legal and ethical obligations.
Speaker Disclosures:
Financial: Kathryn Krase maintains a private practice and has an employment relationship with Social Work Education Assessment Project. She receives royalties as a published author. Kathryn Krase receives a speaking honorarium and product royalties from PESI, Inc. She has no relevant financial relationships with ineligible organizations.
Non-financial: Kathryn Krase is a member of the National Association of Social Workers.
Additional Info
Access for Self-Study (Non-Interactive)Access never expires for this product.
For a more detailed outline that includes times or durations of time, if needed, please contact cepesi@pesi.com.
Questions?
Visit our FAQ page at www.pesi.com/faq or contact us at www.pesi.com/info
Objectives
- Determine the ethical responsibility of mental and behavioral heath professionals to maintain client records.
- Distinguish between the ethical responsibility and related legal requirements of mental and behavioral health professionals to maintain client records
- Identify best practices when reusing content in documentation.
- Utilize strategies that protect client confidentiality whether using physical or electronic health records.
Outline
Protect Yourself from Legal & Ethical Liability
- The 6 Step Decision-Making Framework
- Develop awareness of emerging professional challenges
- Weigh possible responses through an ethical and practical lens
- Take thoughtful, well-supported action with appropriate safeguards
Explore Ethical Codes & Legal Requirements on Record Keeping
- AAMFT
- Code 2.5 – Confidentiality in non-clinical activities
- Code 3.5 – Maintenance of records
- ACA
- A.1.b – Records and documentation
- B.6 – Records and documentation subsection
- NASW
- 3.04 – client records
- APA
- Section 6 – Record keeping and fees
- Federal Law: HIPAA
- Privacy Rule and safeguards
- Patient rights and psychotherapy notes
- Specific State Law Examples
- NY: Expectations, and retention
- CA: Retention rules
Practical Documentation
- Essential content examples
- Security of paper and electronic records
- Benefits and risks associated with the use of templates
- Dangers of note cloning and best practices for reusing content
- Clinical records vs. psychotherapy notes
Special Documentation Issues
- Electronic communications: Ethical risks, consent, and secure systems
- Amending records: Legal process for making changes or corrections post entry
- Client requests for records: Right of access rules and exceptions
Responsibilities around Termination, Job Transitions, and Retirement
- Importance of keeping complete records
- Informing clients (past and present)
- Retention timelines and best practices
Impact of Electronic Health Records (EHR/EMR)
- Legal & ethical implications
- The latest security standards
- Informed consent for digital systems
- Fair information practices
- Post-termination responsibilities
- Client access to EMRs
Special Topics
- Records of minors
- Guidelines for sharing records
- Teletherapy documentation and consent/disclaimers for virtual care
- Using AI in documentation
Target Audience
- Counselors
- Social Workers
- Psychologists
- Case Managers
- Therapists
- Marriage & Family Therapists
- Case Managers
- Other Mental Health Professionals
- Physicians
Reviews
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