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Documentation: An important step in avoiding malpractice​​

A malpractice judgment can seriously harm your personal and professional life. And your file documentation may be the only thing between your word and that of a client’s. Often your documentation may be the sole item of evidence in a case.

Proper documentation is a key element in avoiding adverse legal action. Legally credible documentation involves an accurate record of the care your client received, and your competence in providing appropriate counseling. The file notes should be contemporaneous, accurate, honest and appropriate. Notes should avoid adverse comments about the client.

Ensuring proper documentation

Here are some common sense steps to take to ensure proper documentation:

  • Document the care when it’s provided. Be sure to always note the time and date. This is especially important during an emergency, such as when a client expresses a desire to harm themselves or others.

  • Be sure you indicate exactly what you did. Inaccurate statements are not helpful.

  • Avoid exaggeration or untruthful comments.

  • Remember that file documentation may be subject to a subpoena. You must be comfortable in the knowledge that someone could be reading your notes. View your client as a unique individual with a distinct set of cultural values, beliefs, and attitudes. Include a follow-up plan. State what’s important for the client to do. If consultation or referral is needed, that should be indicated. Be sure to make an appropriate referral if the notes indicate this.

  • Ask yourself these questions in emergency cases. When did intervention begin? When were family and authorities notified? How did the client respond? There will be times when a late entry has to be made. It’s important that the file documentation be clear that the entry is late and when it was entered.

  • Never alter a client’s records. Altering records is a criminal act. It can be especially devastating if any alteration is done after a civil action is filed.

Valuable resources

Always utilize the resources available to you the minute a possible legal problem arises. As an example, there will be help if you receive a subpoena for your records. Contact HPSO immediately if you receive a subpoena or any other document notifying you of legal action. Our HPSO representative will help you with what steps to take to report a possible claim.

For more information about your professional liability coverage, you can contact HPSO at 1-800-982-9491, or send an e-mail to or visit our website at

Paul Nelson, Executive Director, ACA Insurance Trust, Alexandria, Virginia.

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