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The client's authorization is needed to release their therapy records to anyone else, even to trusted family members, and even if those family members are in the therapy session with them. This article contains insightful information on the codes of conduct, confidentiality, and ethics practices that therapists are obliged to adhere by, and how they pertain to group therapy sessions.

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The information in these records is essential for the therapist to keep track of the clients and for other healthcare professionals if the client switches therapists or moves on to further treatment. Clients are also granted access to their own records. The language and circulation processes used in this genre make it relatively simple for others to access (with permission) if need be, but certain terms or systems need to be understood in order for all parties to benefit from this genre.

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The tone and style of language used in these records is professional. Notes can be subjective; however they need to follow guidelines as defined by the profession.
Notes can be thoughts or ideas that the client chooses to share, but often these professional notes will not be taken in the structure of full sentences, but rather as points. This is also true when making observations and taking notes about behavior or symptoms.

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There are some variations in which the therapist will use client or session codes (as shown above) instead of names to also assist with organization while maintaining confidentiality.

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Therapists utilize many genres of writing in their practices including, (but not limited to) research reports, abuse/legal reports, client records, and treatment notes.
Client records will be explored specifically, as these records typically involve a combination of the client's information, detailed descriptions and evaluation of their behavior and symptoms, and suggestions regarding current and future treatment.
These records can be in physical or online formats.
The above example of Client Progress Notes may best be suited for physical documentation purposes, as the therapist can evaluate in detail while maintaining a natural, comfortable, and personal approach to observation.

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Some therapists specialize in the physical aspect, working to help rehabilitate those with physical injuries.
Other therapists work with the mind, treating disorders and dealing with mental health. Therapists may see clients in a group or individually, one-on-one.

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These examples are from corpora and from sources on the web. Any opinions in the examples do not represent the opinion of the Cambridge Dictionary editors or of Cambridge University Press or its licensors.

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These examples are from corpora and from sources on the web. Any opinions in the examples do not represent the opinion of the Cambridge Dictionary editors or of Cambridge University Press or its licensors.

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Typically, client records will contain personal information such as the client's name, date of birth, session date and number, presenting problems, symptoms, observations, and a summary of the session.
The client's personal information is essential for the therapist to keep that client's records organized and separate from other clients, and this lowers the risk of breaching confidentiality.

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Digital records can be stored and shared electronically. Physical records can be uploaded and also shared electronically.  Records are filed and stored in secure areas with other client documents. Computer networks need to be secure to ensure client confidentiality. Only those granted permission (such as other therapists, healthcare professionals, and the clients themselves) can access these sensitive files. Clients are often given the choice to sign up and register an online profile with their therapist or other healthcare provider. These client portals allow access to their own files on a private platform that is only available to them and their therapist or doctor.
HIPAA (Health Insurance Portability and Accountability Act) calls for the regulation of the privacy and accessibility of these records by allowing them only to be shared with the client or other therapists of healthcare providers when needed.
Strict adherence to privacy standards is required when dealing with sensitive documents.

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HIPAA for Mental Health Professionals: The Basics

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Knowing how HIPAA, the Health Insurance Portability and Accountability Act, protects you and your clients is critical. Here’s HIPAA for mental health professionals.

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The community that I am examining is the therapist community. I have chosen this community because it is a field in which I wish to someday have the opportunity to pursue a career in.
Marriage/couples/family therapy is interesting specifically, because this can involve either one-on-one or group therapy techniques. Learning about others, their minds, and the dynamics of various relationships while helping them learn about themselves in these and other ways is truly fascinating.

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This is what a group therapy session record may look like.
Notice that this observation is not just of the group as a whole, but of an individual within the group.