Help! My client requested a copy of their records (and progress notes!)

This is the first video in a series aimed at helping therapists navigate tricky documentation situations. Today, we'll tackle a common concern: Clients requesting copies of their therapy records.

Dr. Maelisa McCaffrey breaks down why clients typically ask for their therapy records, the steps you should take when it happens, and she addresses some frequently asked questions therapists have about the records request process.

Why Clients Request Therapy Records

There are several reasons a client might request a copy of their therapy record or progress notes:

• Court Case: They may need information for legal proceedings.
• Third-Party Sharing: They might want to share details with a lawyer, workman's comp, or employer. (Note: This post focuses on client-directed requests, not requests from third parties.)
• Reviewing Progress: Sometimes, clients simply want to review their progress notes to track their progress.
• Disagreements: In some cases, a disgruntled client might request therapy records as part of a dispute.

Therapist Obligations for Records Requests

In most cases, you are legally obligated to provide clients with a copy of their therapy records upon request. This includes progress notes, with some exceptions for psychotherapy notes (commonly referred to as process notes) covered by HIPAA regulations (you can click here to watch a video explaining process notes).

For records requests it's important to remember:

• Refusing to provide copies of therapy records is generally not an option. You must provide the records unless there's a very significant reason (e.g., it could cause the client physical harm).
• If the records involve couples or family therapy, you likely need consent from all parties involved before releasing any records to any involved person.
• In rare situations, you might deny a copy of therapy records, but typically you'd still need to allow a designated person to review the records on the client's behalf.

What To Do When a Client Requests Therapy Records

Here are the steps to follow for handling a client request for records:

1. Breathe Easy: It's a normal request, and your licensing board understands.
2. Acknowledge the Request: Let the client know you've received their request and outline next steps.
3. Confirm Details: Determine the timeframe for providing the records and how you'll share them (e.g., paper copy or secure online portal).
4. Review the Records: Double-check that the file is complete and accurate.
5. Seek Support: Consider consulting with your liability insurance, professional association, or a trusted colleague for guidance (or all three!).

Addressing Client Upset and Progress Notes

If you're concerned a client might be unhappy and misuse their mental health records or progress notes, here are some tips:

• Review for Errors: Carefully review your notes for any inaccuracies that could be misinterpreted.
• Seek a Review: Ask a colleague for a quality review of your notes to identify any potential issues.
• Fix What You Can: Don't change progress notes you've already written and signed, but you still have options! Add an addendum or note to chart to explain any discrepancies or clarify issues.

What Happens Next?

After providing the mental health records, a few things might happen:

• The Client Moves On: Often, clients simply need the information and you won't hear back.
• Third-Party Review: The client might share the records with someone who ultimately finds them irrelevant.
• Licensing Board Complaint: In the worst-case scenario, an upset client might file a complaint with your licensing board. Don't panic! The board investigates all complaints, and they understand these situations can be unfounded. They'll review your records and interview you separately to reach a conclusion. The process can be stressful, but your liability insurance will likely provide legal support.

Remember, you're not alone in this.

Reach out to close colleagues, your liability insurance, and seek consultation. Maelisa offers individual consultation sessions if you want someone to review your progress notes and talk through potential challenges. Click here to book a consultation any time. 

This series will continue to address common documentation challenges therapists face. Subscribe to the YouTube channel and get regular updates.