Record Keeping
Accurate, consistent, and secure record keeping is at the heart of any private psychology practice, yet it is also one of the most common sources of questions and uncertainty among clinicians and team members. This module addresses the everyday, “nitty-gritty” aspects of managing client records, consent forms, session notes, audits, scanning, and urgent correspondence, providing clear guidance that ensures consistency across the practice.
By embedding these policies and procedures, practices can reduce errors, maintain client safety, and make supervision and team support more efficient. This module also addresses custodianship of client records when a clinician leaves, and includes practical tools to support ongoing compliance and safe practice.
Included in this module are:
- Record Keeping policy and procedure
- File Audit policy and procedure
- Consent Form Audit policy and procedure
- File Destruction policy and procedure(generic)
- File Destruction policy and procedure (Zanda directions)
- Urgent Correspondence policy and procedure
- Session Notes policy and procedure
- Scanning Client Documents policy and procedure
- Custodianship of Client Records When a Clinician Exits the Practice
These resources save time, reduce inconsistencies, and help practices confidently maintain high standards of client record management. These policies are also essential for supporting your practice to be APS private practice management standards and AHPRA code of conduct compliant.
