Failing to maintain adequate client records potentially could lead to a malpractice claim because it breaches the standard of a mental health practitioner.

University of Illinois at Urbana-Champaign

Therapists are ethically and legally required to store records in a secure manner and to protect client confidentiality. 

Record keeping

Vinay, B., Lakshmi, J., & Math, S. B. (2016). Ethical and legal issues in psychotherapy. In Ethical Issues in Counselling and Psychotherapy Practice (pp. 199-217). Springer, Singapore. https://doi.org/10.1007/978-981-10-1808-4_13

Ethical and Legal Issues in Psychotherapy

Failure of record keeping

* General file information
* Documentation of service
* Other information

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