Patient record for psychologists in Belgium: what it must contain

For a clinical psychologist in Belgium, the patient record is everything you write down about each person you see, from their identity to the notes you take session after session. According to the Psychologists' Commission (Commission des psychologues), its content is set by the law of 22 April 2019 on the quality of healthcare practice, which applies to clinical psychologists, recognised as healthcare professionals since 2016.

Which psychologists must keep a patient record?

According to the Psychologists' Commission, the obligation applies to clinical psychologists. Since their recognition as healthcare professionals in 2016, they have specific duties tied to that status, which come from two laws. The law of 22 April 2019 on the quality of healthcare practice (often called the quality law) says what the record contains, in what form it is kept and for how long. The law of 22 August 2002 on patients' rights gives the patient a right to a carefully kept and securely stored record.

What if you are not a clinical psychologist? The Commission says non-clinical psychologists should also strive to follow both laws where they are relevant to their practice. The Commission frames this as a recommendation. If you are a psychotherapist, which texts apply depends on your status. Our article on GDPR for psychologists and therapists in Belgium explains which texts apply to whom.

What does the quality law say the record must contain?

According to the Psychologists' Commission's ethics newsletter (April 2025), article 33 of the quality law lists the items a professional includes in the record at a minimum, within the limits of their competence. The newsletter counts twenty-four of them. The Commission also makes a reassuring point. You only need to include the items that apply to your practice, when they are relevant. Part of the list mainly concerns medicine.

Here they are, grouped so they make sense for a psychologist. This is a paraphrase, not the wording of the law.

Who the patient is, and who is involved

• Patient identification (social security number, name, sex, date of birth, address, phone, email).
• Their general practitioner.
• Your own identification, that of the reference professional if there is one, and that of other people involved in care.

Why they came

• The reason for contact or the presenting problem.
• Personal and family history.
• Test results, for example the conclusions of an assessment.
• Certificates, reports or opinions you received from the patient or from third parties.

The work you do together

• The patient's health goals and their stated wishes.
• The diagnosis you made, if there is one and if it falls within your competence.
• A chronological overview of care, with the type and date of each contact.
• How the situation evolves, where relevant.
• Reports of discussions with the patient, with other professionals or with third parties.
• Referrals to other professionals, services or third parties.
• The patient characterisation defined in article 12 of the same law, where it applies.

What the patient asked for or decided

• Information shared with a trusted person with the patient's agreement, and who that person is.
• A request to be assisted by a trusted person, with their identity and the scope of their role.
• An explicit request from the patient not to receive certain information.
• Your reasons for not sharing a piece of information, if that happened.
• Your reasons for turning down a representative's request, or for departing from their decision.

What rarely concerns a psychologist

The list also covers medication and the medication schedule, complications that need further treatment, and a daily note during a hospital stay. In private practice these items usually stay empty. If you work in a hospital, the daily note may concern you.

The list is a minimum. The newsletter points out that you can add other useful items, such as a child's drawings or creative work made during the follow-up.

Are my personal notes part of the record?

Yes. According to the Psychologists' Commission, all the notes you take about a patient belong in their record. That includes working hypotheses, reflections and subjective observations. Handwritten notes are part of it too. According to the ethics newsletter, a note is “personal” because of its content, not because of how it was written.

What changed is access. According to the Psychologists' Commission, the reform of the patients' rights law, in force since 4 March 2024, lets the patient, their representative or a trusted person consult personal notes. Before that, only a healthcare professional designated by the patient had access. In every case, information about third parties stays excluded from consultation and copies.

What about notes written before 4 March 2024?

Here, two texts from the Commission do not say the same thing. Its “Patient file” web page says all personal notes are accessible, whatever date they were written. Its April 2025 ethics newsletter says that notes written up to 3 March 2024 inclusive can only be consulted by a healthcare professional the patient designates. To be safe, we recommend assuming the patient can read all your notes, and asking the Commission for advice if a request concerns older notes.

How should you write notes now that the patient can read them?

Here is what we recommend.

• Write as if the patient will read it. If you would feel awkward explaining a phrase to them, rework it.
• Keep facts and hypotheses apart. Write down what was said or observed, then your working ideas in a separate part, clearly framed as hypotheses.
• Keep third parties separate. What a parent, partner or colleague told you is best kept apart and clearly labelled, since it is excluded from consultation.
• Stay descriptive. Describe a behaviour rather than judge it, and quote the patient's own words when they matter.
• Note decisions. A goal agreed together, a suggested referral or a request from the patient is more useful in the file than a long narrative.
• Date every note. The chronological overview is on the list, and a dated note is easy to find.

To structure your session notes, the formats in our article on SOAP, DAP and BIRP session notes already separate observation from analysis.

Is a paper record still allowed?

Yes, for now. According to the Psychologists' Commission, article 34 of the quality law provides for an electronic record, but no royal decree has been adopted yet, so this rule is not in force. You can keep a paper record, unless your employer asks for an electronic one.

If you move to digital, we recommend a tool where each patient has a single file with dated notes in order.

What can a patient record sheet look like?

Here is one possible layout. The example is entirely fictional. The patient, dates and clinical details are made up to show the structure.

Record sheet (fictional example)

• Patient. Julien D., 34 (fictional example). Contact details and social security number in the admin sheet.
• General practitioner. Dr X., who referred the patient.
• Psychologist. You, and any other professionals involved.
• Reason for consulting. Trouble sleeping and stress at work for several months, according to the patient.
• Relevant history. A previous course of therapy a few years ago, ended at his request.
• Documents received. Letter from the GP.
• Patient's goals. Sleep regularly again, set clearer limits at work.
• Diagnosis. None at this stage.
• Trusted person. None designated.
• Specific requests. None.
• Referrals. None.

Session note (fictional example)

• Date and type. 3rd individual session, 50 minutes.
• What was said. The patient describes a calmer week. He says “I dared to turn down a project”.
• Observations. Fluent speech, more relaxed than in the first session.
• Working hypotheses. Difficulty saying no seems linked to a fear of disappointing others. To explore with him.
• Third-party information. None today.
• Progress towards goals. Sleep slightly better, according to the patient.
• Next steps. Go back over situations where he refuses at work. Next session in two weeks.

To open the file, our first session intake template helps you cover the reason for consulting and the history. More layouts are gathered in our clinical document templates.

How long do you keep the record, and who can see it?

According to the Psychologists' Commission, the record is kept for at least 30 years and at most 50 years after the last contact with the patient (article 35 of the quality law). Its web page and its ethics newsletter give the same period. The patient can consult the record and get a copy, and you reply within 15 days. The first copy is free. Deadlines, copy fees and the patient's other rights are covered in our article on GDPR for psychologists in Belgium.

How can Delta help you keep the record?

Delta is the clinical assistant for mental health and allied health professionals. During the session, Delta transcribes what is said. You can also dictate your observations right after, or add written notes. Delta then prepares the session report, with a short summary, a detailed summary and topics for next time. It takes your profession and approach into account, for example CBT, EMDR, psychodynamic or systemic work.

Each report updates the patient's file, with a summary of the follow-up and the goals being tracked. You find the whole follow-up and how it evolves in one place. Delta makes no diagnosis. Since the patient can consult their file, we recommend reading over every report.

Data is hosted in France with an HDS-certified host, and no audio file is kept. Delta does not replace your own reading of the quality law. If you want to know more about the hosting standard, see our page on HDS-certified hosting.

Sources

• Psychologists' Commission, “The patient file” (page consulted on 22 October 2026, French version: Le dossier patient).
• Psychologists' Commission, Le Courrier déontologique, “Le dossier patient à la loupe”, April 2025 (PDF, in French).