A previous post sparked a lot of conversation about patient records. I was asked by a reader if patients are allowed to see their records, so I thought I would share what I said, with you:

If you are a therapy patient, you need to know: You have the right to see many, if not most, of your clinical records, at any point in time.

There is a pesky “however”: However, you generally do not have the right to see the therapist’s personal notes that are written during and sometimes after, your therapy session (you have to check with your own state’s regulations).

Those of you who’ve been reading Therapy Soup for awhile (especially the “treatment plan series” and posts on patient rights), know that I feel strongly that many documents, such as treatment plans, treatment goals, and progress measures, are not only important for patients to see, but important for patients to be actively involved in creating them in partnership with the therapist, in the first place.

They should not be a mystery to the patient. Many psychotherapists agree: the more a patient participates in planning his psychotherapy (or addiction treatment), the more deeply he will invest himself in the outcome.

But other types of notes are generally not useful to the patient - seeing the session notes that your therapist takes, for example, generally won’t help you achieve your goals. They also won’t give you a richer understanding about yourself. Session notes are generally notes that therapist writes for his own elucidation and also act as a “memory bank” which he can refer to as needed.

In fact, depending on the therapist’s note-taking style, these may contain technical terms and shorthand that mean little when taken out of context – they may be as difficult to decipher as a foreign language (especially if they are in *my handwriting, see image above). I would venture to suggest that in some cases, reading your therapist’s notes may actually distract you from working on your therapy goals. It could cause you to feel self-conscious – you might start focusing on what your therapist “thinks/feels about you” rather than focusing on how your therapist can help you.

Still, you do need to know your rights. Yes, you have the right to see some, even most, of your records. Check with your state’s health department in order to find out more.

*Genuine sample of what I like to call “my handwriting.”

 


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    Last reviewed: 7 Mar 2011

APA Reference
& C.R. Zwolinski, R. (2011). Your Right To See Your Patient Records. Psych Central. Retrieved on October 2, 2014, from http://blogs.psychcentral.com/therapy-soup/2011/03/your-right-to-see-your-patient-records/

 

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