"Don't write me down": Legal, clinical, and risk-management aspects of patients' requests that therapists not keep notes or records

Abstract

Although many clinicians have reported anecdotally that patients occasionally ask that treatment or evaluation notes or records not be kept, the issue has not been addressed in the literature. This article deals with the problems arising from patients' requests that their therapists refrain from record keeping, first from a legal and regulatory perspective, and then from a clinical perspective. Method: The authors' consultative experience provides examples of variations on the theme of patients' requests not to take notes. Results: While records must usually be kept, there exist narrow exceptions to this rule. Risk-management suggestions are offered as well. Conclusions: All such requests should be met first with exploration, but limits may have to be set in granting the request.