There is more paperwork on your desk now than ever before. In the face of this onslaught, you may not feel too kindly towards yet another article urging you to keep more and better records. Nonetheless, good documentation is your best defense against a serious malpractice claim. The courts view a carefully annotated treatment record as a psychiatrist's testimony on his or her own behalf that he or she practiced responsible medicine during the course of a patient's treatment. There is no simple answer.
Requirements vary from state to state and from practice setting to practice setting.
Below is a brief checklist of things you can do to protect yourself. Know your state's laws and regulations. There are statutes and regulations in some states which require a physician to make a record for each patient and to keep it for a certain length of time. Even when a state has no such statutes or regulations, it is a good idea to archive your records as a hedge against law suits. Most legal experts agree that you should keep patient records at least until your state's relevant statutes of limitations run out.