A survey of the record-keeping practices of clinical psychologists.

The current paper describes the results of a questionnaire survey of the record-keeping practices of clinical psychologists working in one NHS region in the UK. Issues explored include the reasons given for keeping case-notes; the content of notes; security, access, retrieval and destruction of notes; requests for access to notes and knowledge of note-keeping policy. The analysis of data includes a breakdown by years in profession and by speciality. The results are based on 123 returns and indicate some commonly held views and practice, for example that note-keeping is generally regarded as a requirement of professional practice, that notes act for the majority of respondents as an aide mémoire and that clinical psychologists almost universally keep their notes in a specific psychology file even if they also keep notes elsewhere. The results also show much individual diversity and uncertainty as to what constitutes good practice. The authors conclude that despite recent guidance from the Division of Clinical Psychology and the Department of Health, many issues with regard to note-keeping are unresolved, ambiguous and subject to individual and local decision-making. Copyright © 1999 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]