Data protection and record keeping
It is useful for therapists to be able to keep certain records about their clients. The following explains my policy on data protection.
Session notes
When made, session notes may record background information, techniques taught, and any key issues worked on in the session. These will vary in length and detail. Points of concern are also noted.
It is not essential for therapists to have to make session notes, and in most cases no paperwork will be kept about you.
Access to any notes
Under the Data Protection Act, you have a right of access to all notes kept that relate to you.
If those notes contain references to other individuals these may not be available to the you, as protection is also granted to third parties. It may be important for me to explain to you what my notes contain as some notes are recorded in a coded form for record management purposes. If a file includes a letter or additional information from the person responsible for some other clinical care, usually GP or Psychiatrist, consent from the relevant practitioner must be obtained before the correspondence can be disclosed.
SecurityAny notes are kept securely and confidentially and for no longer than is necessary. After 3 years, if a client does not recommence therapy, any paperwork relating to that client is destroyed by shredding and then destroyed either through recycling, burning or
eating.