The effective, efficient and ethical delivery of psychological services requires good case management skills. Case management involves the integration of three interrelated tasks. In addition to the fundamental conceptual task of integrating evidence-based practice with practice-based evidence, which is the essence of the science-informed approach to clinical practice, treatment involves management tasks and documentation tasks. In this chapter, we will outline the key management and documentation tasks associated with specific phases of the treatment process, as well as some tasks that are important at all stages of treatment. Although many case management tasks have a purpose clearly linked to a specific treatment phase (e.g., a good intake report needs to be produced at the start of treatment), two particular tasks with respect to client data are relevant throughout the entire treatment process: keeping good records and maintaining confidentiality (see Figure 8.1).

Keeping good records

Professional practice guidelines stipulate that treatment providers must maintain adequate records of all contacts with clients or other persons involved in the treatment (e.g. family members, physicians), indicating date, time, and place of contact, persons present, and the nature of service provided or action taken. Good clinical records provide a clear picture of the patient and a clear account of what the therapist did, when and why. Documentation of these clinical activities serves several purposes (Luepker, 2003):

• Records can facilitate communication between therapists and patients. Jointly reviewing reports, test results, data on goal attainment, attendance patterns, etc., can help patients to gain insight into and become active partners in their change efforts, while building trust in the process and the therapeutic relationship.

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