Record-Keeping & Note-Taking Guidelines

National Alliance of Counsellors and Psychotherapists (NACP)
Effective: January 2025

1. Purpose

This document provides guidance for NACP members on maintaining clinical records and notes that are ethical, clear, proportionate, and compliant with legal and professional standards. Good record-keeping supports safe, reflective practice and protects both clients and practitioners.

2. Scope

These guidelines apply to all NACP members involved in counselling, psychotherapy, supervision, or related therapeutic services. They apply to:

  • Written client notes
  • Electronic records and practice management systems
  • Supervision notes relating to client work
  • Intake forms, assessments, contracts, and consent documents

3. Core Principles

Records must be:

  • Factual and accurate – avoid speculation, assumptions, or personal opinion
  • Necessary and proportionate – include only what is relevant for clinical, legal, or risk-related reasons
  • Confidential – stored securely and shared only under lawful, ethical conditions
  • Contemporaneous – written as soon after the session as is practical
  • Legible and understandable – use clear language and professional tone

4. What to Record

You should record:

  • Client’s full name, contact details (secured separately if needed), and relevant background
  • Session dates and duration
  • Presenting issues or themes
  • Interventions or approaches used
  • Significant developments, disclosures, or changes
  • Risks identified and actions taken (e.g. referrals, safeguarding)
  • Agreements, cancellations, or endings
  • Any contact outside sessions (e.g. emails, phone calls)

You may also keep:

  • Signed contracts and consent forms
  • Assessment or referral documentation
  • Brief notes on supervision discussions relating to client work

5. What Not to Record

Avoid including:

  • Detailed personal history unless clinically relevant
  • Subjective interpretations, assumptions, or diagnostic labels (unless clinically justified and within your competence)
  • Emotional reactions to the client that are not explored or discussed in supervision
  • Identifying information in supervision notes if anonymisation is possible

6. Digital and Physical Record Storage

  • Electronic records must be stored on encrypted, password-protected systems
  • Paper records must be stored in locked cabinets in secure locations
  • Backups should be made where appropriate, using secure and compliant systems
  • Avoid storing records on shared devices, cloud platforms without agreements, or unsecured networks

7. Data Retention and Deletion

  • Keep client records for a minimum of 5 years after the last contact (or 7 years if required by your insurer or organisational policy)
  • For clients under 18, keep records until they reach age 25, or longer if risk or legal considerations apply
  • After the retention period, records must be securely destroyed (e.g. shredding, digital wiping)

Always inform clients in your contract or privacy notice how long their records will be kept.

8. Access to Records

Under UK GDPR, clients have the right to access their personal data.

You must:

  • Respond to a Subject Access Request (SAR) within 30 days
  • Provide records in a readable, secure format
  • Remove third-party identifiers where appropriate
  • Discuss with a supervisor or legal advisor if there are concerns about potential harm from disclosure

9. Supervision Notes

When keeping notes on client-related supervision:

  • Use anonymised identifiers (e.g. initials or pseudonyms)
  • Focus on process, decision-making, and ethical reflections
  • Do not include identifiable or unnecessary client detail
  • Keep supervision records secure and separate from client records

10. Records in Shared or Organisational Settings

If working within an agency, practice group, or shared space:

  • Clarify who owns the records and how access is managed
  • Ensure data protection policies are in place for shared storage
  • Be mindful of internal protocols and insurance requirements

11. Working with Technology

If using digital tools to keep notes (e.g. apps, practice software):

  • Ensure they are GDPR-compliant and have data processing agreements in place
  • Use secure, encrypted platforms with two-factor authentication where possible
  • Avoid storing clinical data on personal devices unless suitably protected

12. Review and Support

These guidelines will be reviewed annually, or in response to changes in legal or regulatory requirements. If you are unsure whether something should be recorded or how to manage sensitive information, consult your supervisor or contact the NACP for advice.

📩 Contact

For questions or support on record-keeping or data protection:
📧 info@nacp.co.uk
🔗 www.nacp.co.uk