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


