Record Keeping Policy

Helen Ward Therapy
Trading name of ResolvedRM Ltd

Version: 1.0

Effective Date: 30/05/26
Review Date: 30/05/27

1. Purpose

Helen Ward Therapy recognises that accurate, appropriate and secure record keeping is an essential part of safe, ethical and effective therapeutic practice.

This policy sets out the approach taken to the creation, maintenance, storage, access, retention and disposal of client records.

Record keeping supports:

continuity and safety of care;
professional accountability;
reflection and clinical decision-making;
ethical practice;
safeguarding responsibilities;
legal and regulatory obligations.

This policy has been developed in accordance with:

the UK General Data Protection Regulation (UK GDPR);
the Data Protection Act 2018;
the BACP Ethical Framework for the Counselling Professions.

2. Scope

This policy applies to all records created, received, stored or processed by Helen Ward Therapy, including:

client assessment records;
therapy notes;
risk assessments;
outcome measures and questionnaires;
treatment planning information;
correspondence;
appointment records;
consent records;
administrative records;
financial records;
safeguarding records;
professional supervision records where applicable.

3. Purpose of Clinical Records

Clinical records are maintained to support safe and effective therapeutic work.

Records may be used to:

support understanding of the client's presentation and therapeutic needs;
inform therapeutic planning and decision-making;
monitor progress and changes over time;
document relevant risk considerations;
support professional reflection and supervision;
demonstrate appropriate professional practice.

Clinical records are not intended to provide a complete transcript of therapy sessions and will not capture every aspect of the therapeutic conversation.

4. Principles of Record Keeping

Helen Ward Therapy follows the following principles when creating and maintaining records.

Records should be:

Accurate

Information recorded should be factually accurate and based on information available at the time of recording.

Where professional observations or clinical impressions are recorded, these will be identified as such.

Relevant and Proportionate

Only information that is relevant and necessary for the provision of safe and effective therapy will be recorded.

Records will avoid unnecessary personal detail that does not contribute to therapeutic understanding or professional accountability.

Clear and Objective

Records will be written in a professional manner and should distinguish between:

information provided by the client;
observations made by the therapist;
clinical reflections or hypotheses;
decisions and actions taken.

Timely records will be completed within an appropriate timeframe following sessions or significant events.

Respectful records will be written with consideration for the dignity, privacy and wellbeing of the client.

Language used will be professional, non-judgemental and appropriate.

5. Types of Records Maintained

Depending on the needs of the therapeutic work, records may include:

Initial Enquiry and Assessment Records

Including:

contact details;
presenting concerns;
relevant background information;
suitability considerations;
consent and contracting information;
risk considerations.

Therapy Session Records

Session records may include:

date and duration of session;
themes discussed;
therapeutic interventions used;
relevant observations;
progress or changes;
risk considerations where applicable;
clinical reflections;
agreed actions or areas for future exploration.

Assessment Tools and Outcome Measures

Questionnaires, screening tools and outcome measures may be used to:

support assessment;
understand client presentation;
monitor progress;
inform therapeutic decisions.

These tools are used solely for therapeutic purposes and are not reports, opinions or assessments for external use.

6. Confidentiality of Records

All client records are confidential.

Access to client records is restricted to Helen Ward unless disclosure is required or permitted by law.

Information may be disclosed only where:

the client has provided appropriate consent;
there is a safeguarding concern;
there is serious risk of harm;
disclosure is required by law;
disclosure is necessary to comply with professional or legal obligations.

Where disclosure is necessary, only the minimum relevant information will be shared.

7. Storage and Security of Records

Client records are stored securely using appropriate technical and organisational measures.

These may include:

password protection;
secure devices;
encrypted systems where available;
secure cloud storage;
restricted access;
appropriate backup procedures;
secure disposal processes.

Paper records, where held, are stored securely and protected from unauthorised access.

8. Amendments to Records

If factual inaccuracies are identified, records may be corrected or updated appropriately.

Original information will not be altered in a way that removes the integrity of the record.

Where appropriate, amendments will be clearly identified.

9. Client Access to Records

Clients have rights under UK GDPR to request access to their personal information.

Requests will be managed in accordance with the practice Subject Access Request Procedure.

A request for access to records is separate from a request for:

reports;
professional opinions;
assessments;
letters;
statements;
external documentation.

Helen Ward Therapy does not provide reports or written documentation for external purposes except where required by law.

10. Professional Supervision

Helen Ward Therapy undertakes regular professional supervision as required by professional standards.

Relevant aspects of clinical work may be discussed in supervision to support safe and ethical practice.

Information shared in supervision will be managed confidentially and identifying information will be minimised wherever possible.

Supervisors are professionally bound by confidentiality obligations.

11. Record Retention

Records are retained in accordance with the practice Data Retention and Secure Disposal Policy.

Client records are retained for seven years following the end of therapy.

Retention periods are reviewed to ensure information is not kept longer than necessary.

12. Secure Disposal

When records reach the end of their retention period, they will be securely destroyed in accordance with the Data Retention and Secure Disposal Policy.

Disposal methods will ensure information cannot be accessed, reconstructed or misused.

13. Electronic Communications

Information contained within emails, text messages or other electronic communications may form part of the client record where relevant to the therapeutic relationship or professional obligations.

Such information will be managed in accordance with confidentiality, data protection and record retention requirements.

14. Record Keeping and Safeguarding

Where safeguarding concerns arise, appropriate records will be maintained to document:

the concern identified;
relevant information considered;
actions taken;
decisions made;
rationale for decisions.

Records will be factual, timely and proportionate.

15. Client Responsibility

Clients are encouraged to maintain the confidentiality of their own records and communications.

Clients are responsible for protecting their own devices, passwords, email accounts and any copies of information they hold.

Where clients choose to communicate electronically, they acknowledge that maintaining confidentiality is a shared responsibility.

16. Policy Review

This policy will be reviewed annually or sooner where there are changes to:

legislation;
professional requirements;
technology;
practice procedures.