What does the electronic client record contain?
The electronic client record gathers in one file everything the therapist needs to know: identification, history, assessments, therapy plans and documents. Below you see which sections it contains and what the law on sensitive data requires.
Short answer
- Identification data: name, age and contact details.
- Relevant history: presenting concerns, prior therapy and personal context.
- Assessments, the therapy plan and progress across sessions.
- Encrypted session notes, with later addenda, and attached documents.
- Signed consents and an access log, to protect sensitive data.
The sections of a complete record
What the electronic client record contains
| Section | What it includes |
|---|---|
| Identification | Name, age, contact |
| Relevant history | Presenting concerns, history, personal context |
| Sessions and assessments | Sessions, assessments, therapy plans |
| Session notes | Encrypted notes, later addenda, attached documents |
| Consents | Signed agreements and access log |
What data protection requires (in brief)
- Mental-health data are sensitive data and require a clear legal basis for processing (GDPR, art. 9).
- Access is limited to authorized people, and access is recorded in an access log.
- The client can request their data and retention follows the period set by law.
- Session notes are stored encrypted.
Common mistakes
- Keeping records on paper or in separate files, with no single per-client history.
- Leaving all users with full access, with no record of who opened what.
- Not collecting consents and not keeping them attached to the record.
How 4therapy helps
- A single electronic record per client, with history, assessments, therapy plans and session notes in one place.
- Team members can be given a role, and an access log records access; session notes are encrypted.
- Documents and consents attached to the record, with encrypted session notes.