What's in the File? Opening the Drawer on Clinical Record Keeping in Psychology

Authors


Correspondence: Liza Bradford, Centre for Applied Psychology, University of Canberra, PO Box 3017, Manuka, Canberra, ACT 2603, Australia. Fax: +61 02 6295 0129; email: mbpsych@live.com.au

Abstract

Record keeping is a legally required and yet rarely researched aspect of the practice of psychologists. The current study aims to establish an overview of the record-keeping practices of private practitioners. Seventeen psychologists employed in private practice settings were interviewed about their record-keeping practices. Psychologists were asked about the content and utility of their clinical records, training, knowledge of legislation, and their concerns about record-keeping practices. Psychologists also reviewed one of their clinical files and reported on the contents. Thematic analysis of interview transcripts was conducted with the following themes arising: accuracy, accountability, utility of records, compliance with legal and professional standards, opinion versus fact, and time. The limitations of the current study are acknowledged, and recommendations for further research are outlined.

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