Therapists are legally required to keep records, ie progress notes, for psychotherapy sessions. No specific format (eg SOAAP notes) is required, but progress notes must be in keeping with accepted clinical standards.
Paper records and electronic records must be securely stored
Law and Ethics Nuts and Bolts
Generally, records should be kept for 7 years after termination for adult clients. This is not a legal requirement per se, but it allows enough time for most statutes of limitations, in the event your ex-client should ever be involved in a criminal case where your records would be needed. If that happened and you had destroyed the records early, you would be considered negligent.
For child clients, keep records until the child turns 19 (giving them one year after the age of majority to be able to request their own records), or 7 years after termination, whichever is longer.
A client (or whoever gives consent to treatment, eg a child client’s parent) has a right to view their own records, including information in the chart from third parties. It is often clinically ill-advised to give the client a copy. Some therapists ask if the client is willing to view the records without receiving a copy. Legally the therapist has the right to give the client a summary only, and explain that viewing the entire record could cause the client emotional harm.
When giving records to a client, a therapist may charge an administrative fee for photocopying. However, it is illegal to withhold the records from the client because the client owes money for therapy services.
It is important to keep records that will be unlikely to harm your client, or other parties, in case they are viewed by the client or released to others. Therefore:
It is also important to show in your documentation that your own behavior was legally and ethically sound. Therefore:
It is a good idea to keep records of all communications with a client (not just billable sessions) and with any third parties (providers, family members, etc).