Note-Taking in Counselling
Why do we Take Notes in Counselling?
- To aid memory.
- Because of an organisational requirement – for example the BACP or a placement provider.
- The client has a legal right to request their notes under the GDPR (General Data Protection Regulations 2018).
- Client notes may assist either party in the event of a complaint or legal action.
Who May See Session Notes?
Client notes are confidential and may only be requested by the following:
- The client may request to see their own notes, and have the right to view them under the GDPR (General Data Protection Regulations 2018).
- A judge may request client notes with a court order. In these circumstances the therapist must release the notes.
- A coroner may request client notes.
- Under employment law, an agency can ask for your notes. This is rare, however they may ask that notes are stored on the premises and/or on an agency computer system.
What happens if somebody else asks to view client notes?
If a solicitor or other party asks for notes without a court order, the therapist should politely decline. It is important for confidentiality that the therapist does not confirm that they know the client.
The Storage of Notes
Session notes should be kept separately from identifying client information in case they are accessed by unauthorised parties, lost or stolen. Notes should be securely stored. Electronic records should be password protected, and preferably encrypted.
Guidance varies on the length of time 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 observe any relevant agency procedures.
What should Session Notes Contain?
Session notes should be brief and factual, containing concise details of what was discussed in session, and not the personal opinions of the therapist. Any referrals or other action taken regarding the session can be documented in session notes.
Process notes are different to session notes; they are written by the therapist for use in supervision or for personal reflection. Process notes often take a journal-like form, focusing on the process between therapist and client, and the counsellor’s own thoughts and feelings in the work. They can a useful tool for reflection and need not be factual.
Process notes are anonymous – written in a way that completely disguises the client beyond recognition. Unlike session notes, they cannot be requested by the client, however, if a judge or coroner is aware of the existence of process notes, they have the legal power to order their release.
This article was written for Counselling Tutor by Erin Stevens