Applicable Circumstances: Regulatory Investigations / Ethics Review Civil Actions (i.e., divorce actions, child custody disputes) Criminal Actions against client Lawsuits in which the mental health / emotional status of client is an issue (i.e., pain & suffering, disability, etc.) Malpractice Actions Against Therapist (civil lawsuit)   For this Purpose the Record Should: Reflect your capacity & duty to conceptualize a case & devise an appropriate treatment plan Document the assessment of suicide risks & potential for violence (notation of assessment & determination it is not a clinical concern documents standard of care)   If a client is suicidal... Document Assessment of Risk List Options for Prevention List Possible Interventions If symptoms have medical component  (i. e, depression, thought disorder, etc.)-- document considerations of this   Courts & external review boards view absence of documentation regarding services or events as evidence it never happened--- "If it's not on paper, it didn't happen!"