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  • Writer's picturekellyharveylpc

Clinical Notes: May a client read them?

I allow my clients to see their notes if they ask.

Having said that, there are clinical reasons why a therapist may do differently. Therapist notes fall into two categories (at least in the states where I practice). One is the clinician’s private notes. These are the sole property of the clinician. They are under no obligation to share them with anyone. They often include thoughts, scribbles, memory jogs, notations relating to past sessions with this client (i.e. “pattern re: abandment”) or future avenues for inquiry, and are in a shorthand that likely only makes sense to the writer.

One reason a clinician might not share them is that my drawing of a cave might not make sense to you as a signal that in future sessions I want to delve deeper in to the unconscious roots of a problem, but for me (a visual and creative person) that is what it would trigger. Drawing and writing are a part of how I trigger long term memory, and what look like mindless scribbles and spider webs to you are a focusing tool to me as I listen. But you would not see useful information.

The second type of note is the legal clinical note. This contains the date and time of the session, the people present, the diagnosis, any major clinical changes, any interventions used, and if there is concern of danger to the patient of anyone else, a discussion of that danger and how it was addressed/who was notified. Notes may also contain referrals to books, media, doctors, nutritionists (i.e. with eating disorders) and other relevant professionals. Finally, the clinical note typically addresses a plan, whether it’s homework

(ie. a TED talk or book to read) or simply the next session.

Typically, I will share a clinical note with a client who asked, but one reason this is sometimes done with caution is that some diagnoses are confusing or upsetting. Finding out that one is diagnosed with a chronic diagnosis, for instance, is upsetting. It’s important that a conversation has taken place, and the client understands what the diagnosis is, how it was arrived at, and what symptoms led to that conclusion. Usually, this also includes conversation about treatment, likelihood of improvement and management of symptoms. Reading such information without context is tricky; it’s much better done as a conversation. Personally, I fall on the side that information in a client’s note should be written in a way that a client COULD read it at any given time without undue distress. If notes are disrespectful, perhaps the clinician is experiencing burnout and that is reflecting in the notes. RK · Oct 21 writes, I found your answer fascinating, but it did bring up a couple of questions for me. First thing, I respect yours and others view regarding personal notes as being private, and I certainly understand the fear of how the client might react to them. But I can also see how refusing a clients request to see them as a potentially damaging to the trust between the client and therapist, especially if the client already has trust issues. At the end of the day, the only thing that a client would think is in those notes, is thoughts and comments about the client themselves. So refusing to share these with a client could quickly create a division of distrust. When you look at it from this perspective, how could anyone not expect there to be a level of distrust afterwords? I also understand the apprehension of handing a client their clinical notes. But I’m confused as to one of the reasons you gave for why you would be cautious. You made the mention of a client getting upset after discovering that they were diagnosed with a chronic diagnosis. Why would that be the first time they found out that they had a chronic condition? Why would a therapist keep something like that from a client? Wouldn’t that knowledge be empowering to a client? I’m in no way trying to criticize your response or beliefs on this subject. These were just the first things that popped up in my head as I read your response, and was genuinely curious if these things are ever considered or discussed within the profession. Kelly Harvey · Oct 21 Hi RK, thanks for your thoughtful comments. As I indicate, I have always shared my notes with any client who asked. I agree with your rationale that the refusal to share holds the potential to create a rift in the therapeutic relationship.

As a supervisor however, and exposed to a broader range of client concerns, I have seen clients upset by factual information in their records. I agree that the client should be given access, but I would prefer they have the ability to read it with the clinician present, in order to ask questions, clarify perceptions and address concerns. For example, laymen often use therapeutic terms differently than a clinician might. You can turn on a computer currently without seeing someone labelled as narcissistic or borderline.

Being able to explain what ‘flat affect’, ‘positive symptoms’ or ‘negative symptoms’ mean is important. Too, if a client is upset by something in the note, it’s helpful if the therapist can be there to talk it through.

Getting the diagnosis of schizophrenia or bipolar disorder can be troubling, and it's far better that this information is conveyed in a conversation than for a client to read it in their medical record. In addition, some clients can get upset by reading factual, neutral data, such as "client has missed 3 of the last seven sessions, and stating this is because she cannot get up". Clients may interpret such a statement as being critical, when a clinician may see if more of a descriptive and diagnostic tool (pointing toward depression, or disorganized thoughts, for example).

As a parallel, I have a relative who recently discovered they had cancer because the information showed up in their healthcare portal before the doctor spoke to them. Incidents like this are unfortunate and distressing, which is why I feel any notes shared should always be done in person.

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