Informed consent
Consent should explain the service, fees, confidentiality and its limits, how records are kept and how to raise a concern. Keep the signed version and the date together, so you can show exactly what a client agreed to.
Session notes
Structured formats such as SOAP and BIRP help notes stay consistent. Whatever format you use, record what happened, your assessment and the plan, in language a colleague could follow.
Using AI drafts responsibly
- Tell clients when a session is recorded, and why
- Treat every AI summary as a draft to check and edit
- Correct anything inaccurate before saving it to the record
Check local rules.Record-keeping and consent requirements differ by jurisdiction and professional body. Confirm yours with your regulator or counsel.
