When a client begins therapy, the process of compiling their medical records chart and client file within an electronic health records (EHR) system is a critical step in ensuring comprehensive, accurate, and secure documentation of their care. This process involves gathering and organizing relevant client information, adhering to legal and ethical standards for confidentiality and compliance, and ensuring that all necessary details are available to provide effective treatment.

Step 1: Client Intake and Initial Documentation: The first step in setting up a client’s chart in the EHR system involves collecting essential intake information. This typically includes the following information. Demographic Data: Full name, date of birth, gender identity, contact information, emergency contact, and insurance details (if applicable). Informed Consent and Authorization Forms: Clients must sign documents acknowledging their understanding of therapy procedures, confidentiality policies, HIPAA compliance, and any release of information agreements. Financial and Billing Information: If applicable, details regarding payment methods, sliding scale fees, insurance claims, and financial agreements are added to the system. Referral and Primary Care Provider Information: If the client was referred by another professional or is receiving coordinated care, relevant details about their primary care provider, psychiatrist, or other specialists are documented.

Step 2: Clinical Assessment and History: A comprehensive clinical history and assessment is recorded in the EHR, including the following. Presenting Problem and Reason for Seeking Therapy: The client’s stated concerns, symptoms, and treatment goals. Mental Health and Medical History: Any past diagnoses, psychiatric hospitalizations, current or past medications, and relevant medical conditions. Psychosocial and Developmental History: Family history, relationships, educational background, employment status, substance use history, and trauma history. Risk Assessment: Evaluation of suicide risk, self-harm behaviors, harm to others, and any legal issues requiring reporting. Strengths and Resources: Identifying personal resilience factors, support systems, coping skills, and previous therapy experiences.

Step 3: Initial Clinical Documentation: Following the intake, the clinician will complete the initial intake assessment and upload it to the client’s chart. This document provides a structured overview of: Clinical Impressions: Initial observations about mood, affect, cognition, and insight. Diagnosis (if applicable): Using DSM-5-TR or ICD-10 codes, the clinician may enter a working diagnosis. Treatment Plan Development: Initial goals, objectives, and planned interventions are documented in alignment with evidence-based practices.

Step 4: Ongoing Session Documentation: Throughout the therapeutic process, the clinician will continue adding notes and updates to the client’s file, including the following. Progress Notes: Documentation of each therapy session, summarizing client progress, interventions used, and any adjustments to treatment goals. Treatment Plan Updates: Periodic revisions based on client progress, changes in diagnosis, or shifts in therapeutic approach. Collateral Contact Notes: Any communications with other providers, family members (with consent), or case managers. Crisis and Risk Management Documentation: Any significant risk assessments, safety planning, or emergency interventions are logged.

Step 5: Compliance, Security, and Confidentiality: The EHR system must comply with HIPAA (Health Insurance Portability and Accountability Act) regulations, ensuring that client records are stored securely, encrypted, and accessible only to authorized personnel. Key security measures include: role-based access where only authorized clinicians and administrative staff can access specific sections of the client file; audit trails where the system logs all access and modifications to client records; and data encryption and backup, that protects client confidentiality in case of system failures or cybersecurity threats.

Step 6: Transition, Discharge, and Record Retention: If a client discontinues therapy or transitions to another provider, their file must be closed properly: A final session note and discharge summary need to be created with a summary of progress, reason for termination, recommendations, and referrals. Client files must be stored securely for a legally required duration, typically 7 to 10 years post-treatment, depending on jurisdiction. By systematically organizing and maintaining client records in an EHR system, clinicians ensure ethical, professional, and efficient management of therapy documentation while prioritizing client privacy and quality care.

Before the consultation session, I send an invitation to register your client portal account, and share these two documents:

• My Professional Public Disclosure: my education, training, experience, credentials, and approach to therapy
• The Office of Professional Regulation document of Vermont Statutes and the means to file a complaint

Here are the documents included with a therapy agreement and informed consent:

• Practice Policies and Procedures
• Consent for Electronic Communication
• Consent for Telehealth Services
• Consent for AI dictation and transcription services
• No Surprises Act acknowledgment and good faith estimate
• Medicare Advance Benefits Notice acknowledgment

Here is a table of contents of the forms and documents to be stored in your medical chart and file:

• Client Information Form
• Client History Form
• Client Insurance Authorization Form
• Notice of Privacy Practices
• Payment Authorization Form
• Consent For Services
• Emergency Contact & Other Contacts Form
• Authorization to use or disclose Protected Health Information

There are many more documents and forms that will be added throughout your journey, including but not limited to the following:

• Outcome Measures
• Assessments
• Integrative Summary
• Treatment Plan
• Psychotherapy Notes
• Session AI Transcripts and Notes
• Psychotherapy Notes
• Handwritten Session Notes
• Psychoeducational Handouts & Worksheets
• Therapeutic Interventions (Electronic Forms)
• Progress Notes
• Contact Notes
• Disability Determination Summary
• Discharge Summary
• Termination Note