It's always a challenge when trying to decide how much detail to put into your documentation, whether it's for an Assessment, a Goal, or a Service Note.  Do you write the bare essentials?  Or go for a much more thorough and detailed approach?  Here are some tips to consider.

Know the Requirements

Your documentation needs to be compliant at all times with any state or federal laws, some other requirements to consider might be what an insurance company may need.  Or if your agency has specific policies for documentation.  Of course, it wouldn't hurt to check out the APA Record Keeping Guidelines.

Balance Detail for Your Own Protection vs Client Concerns

You never know when your notes, assessments, etc, might be needed for auditing purposes, or even because of a subpoena down the road.  At the same time, your client may wish for you to keep minimal information in their assessments and notes out of privacy concerns.  The best approach would be to be transparent with your client about what you plan to keep in their records.  Keep in mind that in BHC Portal, you can always enter additional details about a client in the Client Comments or Appointment Review section.

Be Specific

Whether you keep terse records, or very detailed accounts, make sure to be as specific as possible.  For example, instead of simply stating that "the client was depressed", try to list individual symptoms they experienced, relating to their depression.  This way your assessments, notes, etc, center around concrete observations or diagnosis, and are do not use language which is open to interpretation.  This not only will help you with audits from licensing boards, but will also assist future providers who may take on the client after you.

* The content of this post is not to be taken as legal advice and may not account for all rules and regulations in every jurisdiction. For legal advice, please contact an attorney.