California Registered Dental Hygienist (RDH) Law and Ethics exam

What type of information should not be included in a client's therapy notes?

1. The client's diagnosis

2. Peer consultation notes on countertransference

3. The informed consent signed by the client

4. The treatment plan

The correct answer is: Peer consultation notes on countertransference

When considering what information should not be included in a client's therapy notes, peer consultation notes on countertransference are the correct choice. This is because peer consultation notes are typically considered confidential and are not part of the official client record. Including such notes in a client's therapy documentation could breach confidentiality and trust, as they often contain personal reflections and professional insights intended for the therapist’s learning and development, rather than the clinical history or treatment of the client. On the other hand, elements such as the client's diagnosis, the informed consent signed by the client, and the treatment plan are essential components of a client's records. The diagnosis is vital for providing appropriate care and treatment, while the signed informed consent is a legal document that outlines the client's understanding and agreement to the proposed therapy. The treatment plan is crucial for guiding the therapeutic process and measuring progress. Therefore, maintaining confidentiality and professional boundaries is key when determining what belongs in therapy notes, making peer consultation notes on countertransference inappropriate for inclusion.