Whether you're a psychologist or a registered counsellor in private practice, the HPCSA's record-keeping guidelines apply to you — and they're more specific than most practitioners realise until they're asked to produce a file years after a client was last seen. (If you're a registered social worker, your equivalent obligations sit with the SACSSP rather than the HPCSA — see the note below.)
Here's what the requirements actually mean in practice.
Keep records for a minimum of 6 years
The HPCSA's guidance sets a minimum retention period of 6 years for client records, measured from the date of the last entry. For minors, this period typically extends until the client turns a certain age plus the standard retention window — always check the current guidance for your specific registration (the HPCSA's Professional Board for Psychology covers both psychologists and registered counsellors) if you're dealing with a minor client, as the exact minor-related extension can differ.
The practical implication: a filing system (physical or digital) that only keeps "active" client files easily loses records that should legally still exist. Your system needs to keep closed files retrievable, not just delete or archive them out of reach.
Records must be accurate, and made close to the time of service
Notes should reflect what actually happened in a session, recorded as close to the session as practically possible — not reconstructed weeks later from memory. This is as much a clinical safeguard as a compliance one: accurate, contemporaneous notes protect both the client's continuity of care and the practitioner if a record is ever questioned.
Structured note formats help, but aren't mandatory
The HPCSA doesn't mandate a single note-taking format, but structured formats — SOAP, DAP, or modality-specific formats like CBT or DBT session structures — make it much easier to demonstrate that a record is complete and consistent. This matters more than it might seem: a haphazard note is harder to defend as "adequate record-keeping" than a structured one, even if the underlying clinical work was identical.
Audit trails matter more than most practitioners expect
Beyond the content of the note itself, being able to show when a record was created or edited, and by whom, is increasingly relevant — both for your own practice management and in the event of any dispute or audit. A system with a clear audit log gives you this by default; a folder of Word documents doesn't.
This applies to registered counsellors too, not just psychologists
Registered counsellors are frequently under the impression that HPCSA record-keeping rules are a "psychologist thing." They're not — registered counsellors are registered under the HPCSA's Professional Board for Psychology alongside psychologists, and the same underlying record-keeping obligations apply, even where the specific scope of what you document differs.
If you're a registered social worker, your professional body is the SACSSP (South African Council for Social Service Professions), not the HPCSA — but the SACSSP's own code carries a closely comparable record-keeping and retention expectation. The specific figures differ from the HPCSA's, so check the SACSSP's current guidance directly rather than assuming the HPCSA's 6-year figure applies to your registration.
How TheraLog approaches this
TheraLog supports HPCSA's record-keeping expectations by design: structured note templates (SOAP, CBT, DBT, Trauma-Informed, Safety Plans, and more), full audit logs, and configurable data retention controls that don't quietly expire files you're still legally required to keep. That said, TheraLog is a tool to help you meet these obligations — you remain the Responsible Party for your own clinical and legal compliance, and structured templates don't replace professional judgement.
For the compliance side of things — POPIA rather than HPCSA — see our POPIA compliance checklist. Or see the official HPCSA website for board-specific guidance.
This article is general information, not legal advice. For guidance specific to your registration, consult the HPCSA (psychologists and registered counsellors) or the SACSSP (social workers).
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