CARL is an acrostic to use with clinical notes: Context. Adequate. Relevant. Limited. Andy Williams, one of our Training Directors talks us through it.

Part of a series of materials to support you to become the best therapist that you can be.

Once of the questions that often comes up in supervision is about clincial notes and how to think about them. There aren’t rules about this but we do support our learners in thinking about this area.

C – Content. Thinking about the context in which we are working whether private practice, voluntary placements, charities etc. Some organisations have local procedures about how to approach clinical notes.

A – Adequate. The notes need to be adequate for purpose. I use them for reviewing treatment week to week and an overall view of the treatment plan. My notes need to be adequate as a reminder of where we have got to in the treatment sequence.

R – Relevant. Its very important that we don’t make conjecture or guess work and only record information that is relevant to the treatment. For example do the details given by the client in check in need to be recorded if they are not relevant to the therapy contract.

L – Limited. The final area in CARL. Think about a boundary around our work. What is in and out but also not putting in excessive details that aren’t linked to their therapy. You may also need to consider time boundaries.

It goes without saying that all clinical notes come under the GDPR regulations and data protection. Do make sure you get consent from the client about keeping clinical notes.

Want to know more?

If you are thinking of starting in private practice, our First Steps to Successful Private Practice 1 day course covers writing and keeping client notes in more detail and GDPR. Go to our Events Diary page for the next course dates.