What type of documentation might a clinical psychologist be responsible for completing?

A clinical psychologist is primarily responsible for maintaining comprehensive documentation that reflects their clinical practice, particularly through case notes and reports. Case notes are essential for recording clinical assessments, observations during therapy sessions, treatment progress, and any changes in the patient's condition. These notes ensure continuity of care and provide a reliable source of information for future reference, whether for the same clinician or for other professionals involved in the patient's care.

In addition, reports are crucial, as they summarize the findings from psychological assessments, communicate treatment recommendations, and may be required for legal or administrative purposes. Such documentation not only supports the clinician's decision-making process but also serves as a legal and ethical safeguard in the practice of psychology.

While research presentations and handouts, patient treatment plans and referrals, and program evaluations and surveys represent significant aspects of broader clinical practice, they are not the primary focus of ongoing documentation by clinical psychologists. Instead, case notes and reports are integral to everyday clinical work, providing a foundation for effective treatment and communication.