Psychology patient record: what data to keep

The patient record is the first document created in a psychology practice. And often, it's also the one that ages the worst. It starts with four basic pieces of information at the first appointment and, over time, becomes filled with loose notes, unlinked consents, incomplete data, and fields that were never filled out.

Organizing the patient record well from the very first session saves work throughout the entire treatment. When information is complete, organized, and accessible, every professional who opens that file has what they need without having to ask a colleague for an update on the case.

A well-organized patient record in psychology includes five blocks: identifying data, administrative and billing data, informed consent, reason for consultation and problem history, and referral or contact information. From there, the file grows with session notes and linked documents. This post covers each block with the specific fields that should be recorded.

What data to include in the patient record

Identifying data

The basics that allow you to know who the patient is and how to contact them:

• Full name.
• Date of birth.
• ID, NIE, or passport number.
• Contact phone number and email.
• Postal address, if needed for billing or reports.
• Occupation and employment status, useful for clinical context.
• Marital status and living arrangements, depending on the approach and type of therapy.

A note on minors: if the patient is a minor, the record must also include the details of the legal guardian or parents who provide consent. This is a legal requirement, not an option.

Administrative and billing data

The information that makes it possible to bill, collect payments, and comply with tax obligations:

• Patient's or payer's NIF, if different.
• Billing address.
• Usual payment method: card, bank transfer, cash, direct debit.
• Fee charged and session frequency.
• Health insurance or private insurance, if applicable, with policy number.

Upon the implementation of VeriFactu for freelancers starting July 2026, having this data complete from the first session avoids having to look for it when there are already ten invoices pending issuance.

Informed consent

Informed consent is mandatory before starting treatment. It must include, at a minimum:

• Practitioner's identity and license number.
• Description of the type of intervention and therapeutic approach.
• Frequency and estimated duration of sessions.
• Cancellation policy.
• Processing of personal data according to GDPR: what data is collected, how it is used, who is responsible for processing, retention periods, and patient rights.
• Patient's or legal guardian's signature.

Ideally, the consent should be linked to the patient's file from day one, with the date and signature recorded. If managed on paper and then there's an inspection or a complaint, locating the signed document can become a problem. The Eholo digital consents are automatically sent, signed, and archived within the record.

Reason for consultation and history of the problem

The clinical section that gives meaning to everything else. Here, it's advisable to record:

• Reason for consultation in the patient's own words.
• When the problem started and how it has evolved.
• Previous psychological or psychiatric treatments, if any.
• Current medication, if applicable.
• Relevant family history.
• Patient's expectations regarding therapy.

Many psychologists complete this section before the first session by sending a pre-appointment questionnaire. This allows them to arrive at the session with the basic context covered and dedicate time to what matters.

Referral and contact information

Information on who referred the patient and who to contact if necessary:

• Referring professional or center, if applicable.
• Primary care physician or referring psychiatrist.
• Emergency contact: name, relationship to patient, and phone number.

In centers with multiple therapists, this section facilitates coordination when a patient transitions from one professional to another or when supervision is involved.

Session records and linked documents

The patient's file is the starting point. After the first session, the record grows with:

• Session notes. Each session should have its clinical note linked to the record. The format may vary (SOAP, DAP, narrative), but it's important that it remains consistent throughout the treatment.
• Questionnaires and their results. Follow-up questionnaires sent before the session or administered during consultation, with their scores linked to the history.
• Clinical reports. Assessment, referral, or discharge reports.
• Attached documents. Reports from other professionals, diagnostic tests, legal documentation if applicable.

When all these pieces are in the same system, the longitudinal view of the case can be understood at a glance. That's what makes the record a useful, accessible, and easy-to-maintain clinical file. The Eholo online medical record is designed so that each piece is automatically linked to the patient.

How to organize the record from the first appointment

Order matters as much as content. Three helpful criteria:

1. Complete administrative tasks before the session, not after. If the patient can complete their identification, billing, and consent information before arriving, the first session can start with the clinical aspects. A pre-appointment questionnaire serves this purpose.

2. An empty field is a decision, not an oversight. If you decide that profession or marital status are not relevant to your approach, you can leave them out. What causes problems is a field that should be complete but is empty due to an oversight. It's better to define which fields are mandatory in your record and which are optional.

3. Link each document to the patient from the moment it is created. A signed consent form stored in a generic computer folder is difficult to retrieve and prove. A consent form linked to the patient's file is always where it should be.

Paper record, spreadsheet, or clinical software

Each format has its limitations:

Paper. Works for very small practices with few patients. Beyond a certain volume, locating a document, maintaining traceability, or complying with GDPR in a physical folder becomes complicated.

Spreadsheet (Excel, Google Sheets). Intermediate solution. It allows searching and filtering, but lacks role-based access control, does not link documents to the patient file, and does not comply with GDPR for health data without additional measures.

Specialized clinical software. Eholo unifies patient records, clinical history, consents, questionnaires, session notes, and billing in a single system. Each field is linked to the patient file, with role-based access control and encryption. When the practice grows or clinical supervision is required, this structure is already in place.

FAQs

What information is mandatory in a psychology patient record? At a minimum, the patient's identifying information (name, contact, date of birth), the responsible professional's details, signed informed consent, and the reason for consultation. Professional associations publish specific guidelines by autonomous community that should be consulted.

How long must patient records be retained? Regulations vary by autonomous community. As a general reference, the Patient Autonomy Law establishes a minimum of five years from discharge. Some professional associations recommend longer periods, up to fifteen years. It is advisable to consult local regulations and those of the association to which you belong.

Can Google Drive be used to store patient records? The free version of Google Drive does not sign a data processing agreement for health data, lacks role-based access control, and does not guarantee the technical measures required by GDPR for health data. For patient records and clinical files, it is advisable to use a system designed for the healthcare sector.

Are patient records and clinical history the same thing? The patient record is the starting point: identifying and administrative data, and consent. The clinical history is the living document that also includes session notes, questionnaires, diagnoses, reports, and the evolution of treatment over time. The patient record is the entry point to the clinical history.

What happens if a patient requests access to their record? The patient has the right to access their personal data and clinical history. GDPR obliges the professional to provide this access within a maximum period of one month. Having data organized in a centralized system facilitates this management.

Get organized today for a better tomorrow

A well-organized record from the first appointment is a fifteen-minute investment that pays off hundreds of times throughout treatment. Every note, every questionnaire, and every document linked to the patient file adds to the history and simplifies clinical work, coordination with other professionals, and legal compliance.

If you want to see how all of this is organized in a single system, with psychology-specific fields and documents linked to the patient file, take a look at patients and clinical history in Eholo.

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