VHG clinical record keeping good practice guidance for all network therapists

VHG clinical record keeping good practice guidance for all network therapists

VHG clinical record keeping good practice guidance for network clinicians

Authors:

Liz Smith (Senior Counsellor), Angela Jones (Senior CBT Therapist)

Date:

01/07/2024

  

1.    Background information/purpose of this document

VHG’s network has grown considerably in the past couple of years. We usually have over 500 network providers active on our network at any given time. This means the records kept by our network clinicians on our systems are the main mechanism we have for quality assurance, information and risk assessment. Contemporaneous notes also help our oversight team to ensure that therapy aligns with the relevant NICE evidence base and guidelines where applicable. 

This guidance is designed to support you and your clients in your therapy journey together and also to support us as a clinical oversight team to assure the quality of therapy for CBT, counselling and other modalities.  

This general guidance is applicable to all network therapists across all modalities. There are specific guidance documents for CBT and counselling in the relevant sections that detail VHG's standards for clinical notes for different types of therapy. 

2.    General guidance for all modalities and practitioners

 All session notes should be completed within 24hrs of the session taking place.

  1.  Clinical notes should be written in clear, professional English and be free from jargon.
  2. Notes should be factual and report the information given to the practitioner by the client, in their words as much as possible.
  3. Notes should not contain the practitioner’s subjective opinions about the client or anyone in the client’s life. This includes speculation about any diagnosis or conditions the client may meet the criteria for, if this has not specifically been disclosed in the referral, by the client or identified as an area they wish to explore in therapy.
  4.  Notes should detail the specific themes/content of each session and be personalised. No part should be copied and pasted from previous sessions or templates.
  5. A full risk assessment should always be completed in the first session with a client.
  6. All client contact should be documented on the case management system, including clients contacting to cancel/rearrange sessions, therapists contacting clients to advise them of sickness, etc (please see good practice guide around managing unplanned absences from work here: VHG guidance on appointment cancellations/postponements by therapists (zohodesk.eu)) 

Please always keep in mind that clients can request their notes via subject access requests both during and after therapy. Therapy notes can also in rare cases be requested as part of court proceedings.

3.    Extension requests and clinical review requests (all modalities) 

  1. Clinical review requests should be made in accordance with VHG process, be clinically appropriate and set out clearly what support/input or decision is required from the VHG clinical team.
  2. Extension requests should be made in accordance with VHG process, be appropriate to the client and the tenancy, specify a number of sessions needed, and provide a suitable clinical rationale for additional sessions.

Please see the following example of an additional session request for CBT: CBT notes with additional session request (zohodesk.eu)

Please see the following example of an additional session request for counselling: MPB Counselling notes example - with additional sessions request (zohodesk.eu)

4.    Where to access additional support 

The clinical support team can be contacted at network.clinical@vitahealthgroup.zohodesk.eu if you need any further advice, support or have any questions about this guidance document.