Tag Archives: Records

Client Requests for Records

therapyI had a session today in which a client asked to see the notes I have taken that are part of her chart.  I told her I’d have to talk to my supervisor because I’ve never had a client ask for this before.  What choices do I have in deciding whether to give her the notes or not?

This issue was addressed by HIPAA, which created a national standard for client’s access to all medical records including records of psychotherapy.  Under HIPAA, the record belongs to the client and s/he has a right to request and receive a copy.  Exceptions are only made for instances where viewing the record would cause serious harm to the client and, in the case of child records requested by parents, harm to the psychotherapy relationship.  Most behavioral health agencies ask clients to make a written request and then provide a copy of the records within 1-3 weeks.

While HIPAA addresses client access to records from an administrative perspective, it doesn’t address the clinical issues that are often present when a client requests a copy of the current treatment record.  Your supervisor can be helpful in talking through the meaning and motivation for your client bringing this up with you.  Some factors to consider are the client’s previous experiences of secrecy and betrayal, issues of control and helplessness, interpersonal suspiciousness, and involvement in a legal case or application for disability.  Your client is more likely to tell you about the reasons she wants to see your notes if you make it clear first that you plan to honor her request.  In your next session, you can say “You told me last week you wanted to see the notes I have written for your chart.  I have the written request here for you to fill out, and I also am interested in what led you to ask for the notes.”  You can explore this further, if the client is willing to do so, by asking what she expects to see in the notes and how she feels about looking at them.

Most clinicians, especially those in field placement or practicum training, feel anxiety when a client requests the record.  You may anticipate, correctly or incorrectly, that the client will be upset or offended by things you have written in progress notes or the assessment.  Your assessment may include a diagnosis and case formulation that you haven’t explicitly shared with the client.  Your notes may accurately reflect some of the client’s obstacles to improvement and progress.  It is usually helpful to look at the record and to have your supervisor review it to identify anything that could be problematic.  Whether or not you anticipate a negative reaction from the client, it is usually wise to say “There may be portions of this record that spark questions or upsetting feelings for you.  I’d like to talk with you about anything that comes up after you’ve read it.”  Then you should follow up with a discussion in the following session about what it was like for her to look at her record.  If she has questions or was distressed by anything you wrote, I recommend being straightforward in your explanation.  If you regret anything you wrote, you can acknowledge that you wish you had used different wording or had described the situation differently.  In addition to negative feelings, she may feel pleased with her self-assertion and have an increased sense of empowerment when you respond to her request in a respectful, professional manner.

I hope you find this helpful in handling client requests for records.  Please email me with comments, questions or suggestions for future blog topics.