Once-upon-a-time therapists actually wrote notes about their sessions with clients for the sole purpose of assisting themselves in the process of providing thoughtful, quality mental health treatment.   Ahh... those were the days! Now, of course, our clinical records are multi-purposed: Support of Treatment A Legal Document Justification for Third Party Reimbursement Determining what to include and what to exclude is a confusing and sometimes anxiety-provoking experience.   Resources that may be of assistance: Elements of a Reasonable Clinical Chart Clinical Documentation In the Legal Arena   Washington State Law: Minimum Content Requirements Option of No Clinical Notes Retention Patient's examination and copying Requirements Correction or Amendment of Record How much can you charge for copying records? Articles of Interest: Clarity In Staff Notes Clarity in Documentation Analysis of a Group Note Record Keeping Guidelines Record Keeping Retention Practices "Psychotherapy Notes" Under HIPAA Clinical Record Keeping: Damned if You Do, Damned if Your Don't! Protecting Privacy with the Absence of Records Record Keeping Workshop:  Workshop Description Miscellaneous Materials HCFA 1500 Form (Printable Format)  requires Acrobat Reader