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Should the Client’s Assessment be Kept in the Medical Record?

Gabrielle Juliano-Villani, MSW, LCSW

March 25, 2022

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Question

Should the client’s assessment be kept in the medical record? 

Answer

When assessing a client, regardless of the assessment tool that I use, I keep the actual assessment in the client’s record. I currently use an EHR (electronic health record) system, and that system is designed to keep the assessment tools within the client’s chart/medical records. 

Even before I used an EHR, I would just keep the assessment in the client’s chart. It is helpful to refer back to the assessment, especially if we are doing it again in a couple months. It is nice to refer back to the assessment and be like, "Okay, before you said you were having thoughts of hopelessness, like constantly, and now you're not." 

That also helps us track the client’s progress, and to show if the modality that we are using is working. It is also helpful to keep the complete assessment in the client’s chart because we can always refer back to it, to those really specific issues and not just the score.

 

This Ask the Expert is an edited excerpt from the webinar,  Documentation in Social Work for Private Practitionerspresented by Gabrielle Juliano-Villani, MSW, LCSW


gabrielle juliano villani

Gabrielle Juliano-Villani, MSW, LCSW

Gabrielle Juliano-Villani is a licensed clinical social worker and the Clinical Director of Colorado In-Home Counseling, a group practice based in Colorado that provides telehealth and in-home sessions to adults, older adults, and those with disabilities; with a focus on grief/loss, chronic health issues, trauma, anxiety/depression, and caregiver issues. Gabrielle has been in private practice since 2017 and before being in private practice she worked in child protective services as a victim’s advocate, residential treatment, and an in-home care manager with an insurance company. She is the founder of GJV Consulting and Training, where she provides consulting on clinical issues and how to grow beyond the 1:1 model. When Gabrielle is not working, she is at the beach reading a psychological thriller or teaching Zumba.


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