A mental health professional, on average, can see patients, catch up on the latest research, and take substantial time doing administrative work. You could also spend a significant amount of time maintaining patients' records. Maintaining up-to-date patient records might appear burdensome, given the distraction of patient care. However, even though keeping thorough and accurate mental health records might seem like a chore, it is crucial to any medical practice. Not only is mental health documentation essential to care for your patients correctly, but it is also critical to protecting your livelihood and license.

Deficiencies in mental health recordkeeping could affect your profession in the event of an action by the Medical Board. You could also face probation or revocation of your license if you fail to maintain adequate and accurate records per the law. If you are under board investigation for failing to keep proper records, an experienced attorney can help you. Considering the time and money you have invested in obtaining your psychotherapy license, you should not fail to contact an attorney. You should not allow a single violation of failing to maintain proper patient records to make you lose your professional license.

What Must You Include In Mental Health Records

Mental health records must contain a range of information. The type of information you gather should be specific to your profession and business. Some of the information that must be in your patient's record includes the following:

  • Your patient's full name
  • Contact information
  • Date of consultation
  • Your patient's medical history and lifestyle, where these are necessary to the service or treatment
  • A brief description of the treatment or therapy given
  • Unusual reactions to the treatment or therapy
  • Information about patch tests performed, if applicable
  • Any contraindications and allergies
  • Any medication your patient is taking
  • Recommendations or advice you give
  • Relevant comments your patient made about the therapy you offered
  • Treatment records like past medication, experience, and results
  • Details of aftercare advice
  • Any permitted forms should be on the record
  • Your patient must sign the form

You do not need to update the above information every time you see a patient. Still, it is vital to give a patient the chance to update their medical details via the questionnaire the patient completes before treatment.

You should update your patient records whenever the patient comes in for a mental health consultation or service. You could use practice management software to do this because it effectively ensures your records are up-to-date.  

The Importance Of Mental Health Documentation To The Practitioner

Documentation is vital to mental health practice and critical for many reasons. Some of the benefits of keeping mental health include:

Legal Protection

Documentation can offer legal protection to mental health professionals. Complete and accurate records can protect you from legal action, like malpractice allegations. It can also be used to show compliance with legal and ethical standards for the practice of mental health medication. Acting and behaving professionally and upholding the standards of your profession will help you avoid falling behind in your record-keeping.

Quality Assurance And Improvement

Recordkeeping is vital for quality assurance and improvement in mental health practice. Mental health professionals can track the progress and outcomes of their treatments by carefully noting their clinical work. Documentation can also help them identify areas for improvement and make changes to their practice as needed. Similarly, recordkeeping can help a mental health professional assess the effectiveness of mental health interventions and identify best practices. For example, you could realize when reviewing your notes that a particular form of intervention tends to be very effective for specific categories of patients. Documentation can allow you to make this discovery that you could otherwise miss. It is helpful to have those experiences noted so that you can learn from your clinical experience.

Continuity Of Care

Recordkeeping is essential to ensuring continuity of care for your patients. An accurate record of any previous medication can help if a patient switches mental health professionals. Documentation allows the new mental health professional to access the patient's history, medication, and outcomes. This documentation will assist the patient in receiving coordinated and consistent care, regardless of whether the mental health professional is providing the care.

Communication And Collaboration

Recordkeeping is a crucial tool for communication and collaboration between mental health practitioners. Mental health professionals always work in teams, and this gives them the opportunity to exchange information. Maintaining records promotes coordination of care between team members. Documentation can enhance communication with other healthcare professionals, like social workers, nurses, and physicians, who could be involved in the patient's care.

Legal And Ethical Requirements

Mental health professionals have ethical and legal duties to keep records of their work with patients. Generally, they must keep accurate and complete records of the patient's treatment, the necessity for treatment, treatment planning, progress, and patient response and outcomes. Maintaining accurate records is part of the mental health profession's accountability. It also helps them to ensure that they comply with ethical requirements for mental health treatment. Documentation attests to their having provided competent treatment services to patients. Legal compliance is one of the fundamental reasons for keeping clinical files.

Improved Patient Management

Maintaining comprehensive and up-to-date patient records can help you know the patients who filled out their consent forms and those who have not. Having all these forms in your patient's record and available at your fingertips informs you before each appointment. Record keeping is key to effective patient management.

Creating A Scalable Career

You could handle all your patients when you start your business. Unfortunately, this is not scalable. Comprehensive patient documentation will allow you to develop a system that empowers qualified practitioners in your practice to handle any patient.

The practitioner can simply log into the patient record to access past medical history and treatments. It could also benefit the patient because he/she could book in with any practitioner and know that he/she will have a consistent and cohesive experience.

Building Patient Relationships

Some of your patients will require your services only every few months or so. You might not remember what you discussed in the last appointment unless you have a fantastic memory. A lack of records can make developing that personal relationship challenging. Your patient records come in handy since records can serve as a mine of information, which you could use to establish that personal relationship with your patient.

Keep notes with conversation details, personal anecdotes, or anything you wish. All these bits of patient details will help you make your patient feel remembered, valued, heard, and seen, and nothing could beat a relationship like that. Building a strong bond with new patients is necessary because it makes them feel welcomed and more likely to become regular patients, enhancing client retention.

Data Privacy And Security

Handling mental health patients also means your business gathers and stores sensitive patient data. You must keep their data safe and secure. Regulations like HIPAA impose stringent data regulation measures, requiring mental health institutions to protect patient data proactively. The only way to ensure your patients' personal data privacy and security meets the required standards is to have up-to-date patient records. Having updated client records with relevant and accurate information minimizes the risks of miscommunication, data leaks, and errors that could compromise patient privacy. Your patients will always entrust you with their sensitive and personal information. Keeping this information accurate and up-to-date builds stronger relationships and loyalty.

Disciplinary And Corrective Actions For Mental Health Record Documentation Errors

Failure to maintain adequate and accurate mental health records amounts to unprofessional conduct under California law. This claim could attract serious repercussions, including potential revocation of your psychotherapy license. You could face a public reprimand instead of probation or revocation if a complaint entails several acts with a single patient.

For most mental health professionals, there are various claims about failure to maintain adequate and accurate records. The claims include:

  • Alteration of mental health records
  • Failure to maintain adequate records
  • A charge for failure to maintain records linked to controlled substances and permitting access to these records to the Medical Board or its designee

The above claims could attract disciplinary actions, which could include:

  • A minimum punishment of stayed license revocation and probation that does not exceed five years for altering mental health records. You could also face a maximum punishment of revocation of a psychotherapy license.
  • A minimum punishment of stayed license revocation and probation that does not exceed five years for failure to maintain adequate and accurate records. You could also face a maximum punishment of revocation of a psychotherapy license.

A Public Reprimand

Also known as reproval or letter of public reprimand, this is a form of discipline meted out by the healthcare licensing board for minor violations of the law. This discipline will remain on your record and can taint your reputation. It does not include any restrictions on your psychotherapy license. For this reason, it is a popular outcome of an investigation/ disciplinary process if the case itself cannot be dropped.

You could also be ordered to take courses on medical recordkeeping,  prescribing practices, and professionalism or enroll in a clinical competence program. The board can also impose other conditions, like monitoring practice or billing, such as prohibition of practice. You can also face a 60-day suspension for alteration of records.

You might have an opportunity to resolve a claim regarding mental health records documentation depending on the specific facts of your case. You can do this before the board files a formal accusation against you. However, your licensed defense attorney can develop a comprehensive strategy to defend your license and livelihood.

During Board Investigations

Your first step should be to reach out to an experienced attorney as soon as you learn of an investigation or allegation against you for mental health record issues. An investigation by the board or the Department of Consumer Affairs (DCA) is a formal process that can attract disciplinary action and even criminal charges. Before speaking to the investigator or signing any documentation, you should consult with legal counsel. Your attorney will conduct a proper investigation and develop a plan to resolve the matter most favorably.

In some situations, the licensing board can recommend corrective action rather than filing a formal accusation against you. The board will likely do this if the investigators determine that a minor violation of the law has occurred or that the accusation could be mediated. If accused of mental health record errors, you might have to take a remedial course or a Continuing Medical Education (CME) on medical record keeping. You could also face an administrative citation and fine.

The investigation stage, albeit confidential, is the most critical time of the disciplinary process. At this point, your attorney can advocate for you and table mitigating evidence before the investigators. Your attorney can negotiate for corrective action instead of a formal accusation or disciplinary action. Your case will become public, and specific documents will appear on your Breeze profile after an accusation filing. You must consult an attorney immediately after learning about a claim or investigation against you.

Defense Against Failure To Keep Or Maintain Adequate Mental Health Records

It is possible to challenge the claims of failure to keep or maintain adequate and accurate mental health records. Your attorney will gather sufficient evidence to show that you appropriately maintained the mental health records. An attorney can bargain a stipulated settlement, which could lead to a far more favorable outcome than you could have otherwise been able to achieve.

You can opt to have your case heard in a hearing before an administrative law judge (ALJ) at the Office of Administrative Hearing (OAH). Your attorney will present evidence during the hearing. The attorney could also question witnesses and make arguments in your favor. The judge will then make the final ruling, which the board will review before disciplinary action is imposed or your case is dropped.

However, a new law makes fighting these types of claims more costly to psychotherapists. The new Business and Professions law permits the board to pursue recovery of the expenses associated with investigating and imposing disciplinary actions. The expenses could be part of the agreed-upon settlement or as a requirement by the judge at the instruction of the board. For most psychotherapists, the potential to be ordered to pay the cost the board incurs, including the cost of the Office of the Attorney General, apart from their pocket, is overwhelming. The cost recovery is another factor that should be weighed in consultation with an experienced attorney.

The Period You Should Store The Records Of Your Mental Health Patients

The period required to store your patient's records depends on the area of operation and the mental health service you offer. The storage time for patient records in the medical field can vary depending on the specific professional guidelines and the state regulations. HIPAA does not have a specific retention period for medical records. However, keeping the patient's records for as long as possible is good. A lawsuit can be filed up to three years after a patient becomes aware of a problem.

Ways Of Maintaining Records For Mental Health Patients

There are many ways of maintaining your patient's records, but some are better than others. Most mental health professionals start with pen and paper but realize later that it is limiting. Paper records are hard to manage, costly to store, take up valuable space, and prone to water or fire damage. You also must be on-site to access paper records.

Digital patient records allow you to work smarter and faster with the added value of increased availability, compliance, and security. Practice management software is a comprehensive digital device that a mental health professional can use to streamline administrative & operational tasks, give patients the perfect experience, and optimize workflows. This system stores patient details in a single digital, cloud-based location, making it easy to update and access records from anywhere.

A mental health professional only requires a wi-fi connection. This system also integrates robust patient records. This can include everything a mental health expert requires to know about their patients, like medical conditions, patch tests, and treatment plans. You can access everything you require to know with a click.

Find a Competent License Attorney Near Me

Are you a mental health practitioner in Long Beach and are currently under investigation for failing to maintain proper patient records? Our skilled attorneys at the Legal Guardian can help. It does not matter whether your case is intricate or straightforward.

Do not face the board alone, even if you consider yourself innocent. You need an attorney with comprehensive experience in license defense. An attorney has probably handled other cases similar to yours and understands how the system works. Our attorneys have what it takes to handle your case. For many years, we have helped many medical professionals undergoing board investigations for failing to maintain patient records or for committing other violations. You can count on our practical and unwavering support. Contact us today at 866-448-6811 for legal representation you can count on.