Note-Taking in Counselling

Feltham and Dryden (1993: 122) define note-taking as ‘writing observations on clients’.

Purpose of Counselling Notes

We take notes in counselling for a range of reasons:

• They serve to aid our memory when recapping prior to the next session.
• Our agency and/or professional body may require us to take notes – for example the Ethical Framework for the Counselling Professions (BACP, 2018: 6) states: ‘We have agreed that we will … work to professional standards by … keeping accurate and appropriate records.’

• The client has a legal right to request their notes under the General Data Protection Regulation (GDPR).
• Client notes may assist either party in the event of a complaint or legal action, serving as a valuable audit trail.
• They can be useful in facilitating professional reflection.

Indeed, it can be very helpful to review your counselling notes before clinical supervision, and it is wise to discuss your note-taking practice with your supervisor.  Rye (2017: 123) writes:

‘You need to discuss with your supervisor to check that your notes are appropriate for your professional needs and comply with the requirements of the Information Commissioner’s Office.’

Confidentiality and Its Limits

Client notes are confidential, but may be requested by various people:

• The client may ask to see their own notes, and has the right to view them under the GDPR.
• A judge may request client notes with a court order (sub poena). In these circumstances, the therapist must release the notes.
• The police may request notes; you don’t have to release them unless a court order is acquired or the client gives you their written permission.
• A coroner may request notes if the client has died.
• Under employment law, an agency can ask for its counsellors’ notes. In most agencies, however, session notes are required to be stored on the premises and/or on an agency computer system; this means that the agency will usually already have access to them, and so have no need to ask you for them.
• The executor of a will or a relative can request the release of NHS health records (including any counselling notes) if the client dies.

Particular issues to bear in mind in terms of client confidentiality – and so to cover in contracting – are:

• what the limits of confidentiality are
• who can access which notes
• for how long notes are retained
• agency policies on disclosure, and on sharing notes with other bodies where there is inter-agency working.

When Notes Are Requested

If you receive a phone call requesting that you release client notes, it’s important to be cautious, checking out carefully that the person calling is who they say they are and really does have the authority to request the release of notes.

Make sure you take a note of the caller’s name, position and organisation – together with a landline number; if the caller claims only to have a mobile number, this is a sign that the call may not be authentic.

Even if the person is confirmed to be a solicitor or police officer, you should politely decline to release notes. It is important for confidentiality that you do not confirm even whether you know the client.

If your client notes are requested, contact your insurance company, supervisor and agency (if applicable) for guidance.

Writing Notes

It may be unclear whether the term ‘notes’ refers simply to the clinical notes (where the factual themes are recorded briefly in writing) or also to the counsellor’s process notes (which, by nature, may include conjecture).

When to Write Notes

Should therapists write notes during or after sessions? Different modalities may use different types of notes and note-taking practices.

For example, CBT generally involves more use of paperwork during sessions, while person-centred counsellors would very rarely write notes in the presence of clients, instead doing so from memory after the client has left. The latter would generally assert that taking notes during their type of therapy would detract from the therapeutic relationship.

However, even a person-centred therapist might ask whether the client minded them taking notes during the session if some particularly complex information was being provided, or a safeguarding issue had cropped up.

Storing Notes

Session notes should be kept separately from identifying client information in case they are accessed by unauthorised parties, lost or stolen. Some agencies use a ‘split note‘ system to do this, with the notes being written anonymously and identified only by a code. The key to cross-matching this with client contact details is stored separately.

Notes should be securely stored at all times. For agencies that operate from satellite clinics but store notes at their base, electronic notes systems are ideal – but if paper notes are used, these must be transported in a locked bag, and never left unattended (e.g. in a car boot) by the therapist. Electronic records should be password-protected, and preferably encrypted.

Guidance varies on the length of time that notes should be stored. However, insurance companies usually recommend that notes are kept for between five and seven years, at which point they can be securely destroyed. It is important to check with your insurance company and to observe any relevant agency procedures.

The original article on which this longer piece is based was written for Counselling Tutor by Erin Stevens.

References

Feltham C & Dryden W (1993) Dictionary of Counselling, Whurr

Rye J (2017) Setting Up and Running a Therapy Business, Karnac