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By: Jeffrey E. Barnett, Psy.D.
Barnett, J.E. Effective documentation for counselors and psychotherapists:
Clinical, ethical, and risk management issues. In VandeCreek, L., & Jackson,T. (Eds.), Innovations in Clinical Practice, (pp. 237-253). Sarasota, FL: Professional Resources Exchange.
Copyright Professional Resource Exchange, Inc.
Reprinted with permission. Further electronic/printed circulation or duplication is strictly prohibited without explicit written authorization from Professional Resource Exchange, Inc.
Documentation and record keeping are of importance in helping counselors and psychotherapists to provide quality mental health services, to meet legal and ethical standards, and for carrying out effective risk management strategies. This contribution will address these issues, provide the rationale for timely and thorough documentation, and offer specific suggestions for counselors and psychotherapists to use.
CASE EXAMPLES*
*These case examples are fabrications and do not represent any individuals known to the author.
ETHICAL AND CLINICAL ISSUES
ETHICAL AND LEGAL STANDARDS
The mental health professions each stress the importance of providing services to clients and patients in an ethical and competent manner. As indicated in their respective ethics codes (e.g., American Association for Marriage and Family Therapy, 1991; American Psychiatric Association, 1993; American Psychological Association, 1992;
National Association of Social Workers [NASW], 1996), timely, thorough, and appropriate documentation is mandated for services to be provided in an ethical manner.
For example, the American Psychological Association code of conduct (1992) states:
Psychologists appropriately document their professional and scientific work in order to facilitate provision of services later by them or by other professionals, to ensure accountability, and to meet other requirements of institutions or the law. (p. 1602)
Another example of relevant guidelines is provided for social workers in their ethics code (NASW, 1996), which states:
Social workers should take reasonable steps to ensure that documentation in records is accurate and reflects the services provided. Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future. (p. 20)
Not all mental health professionals are members of their respective professional associations. Accordingly, they may not be obligated to adhere to the code of ethics endorsed by that professional organization. Nonetheless, clinicians should be cognizant of any documentation requirements promulgated by their state licensure board as there may be specific documentation requirements included in a profession’s licensure law.
For example, in Maryland, psychology’s licensure law (Health Occupations Article section 10.36.05, 1992) states:
A psychologist shall keep records of a patient’s condition and assessment results, and shall:
(1) Make provisions for maintaining confidentiality in the storage and disposal of written and electronic records;
(2) Ensure that professional records are maintained for a period of not less than 5 years after the date of service;
(3) Limit access to client records and ensure that a person working under the psychologist’s authority complies with the requirements for confidentiality of client material;
(4) Provide timely evaluation or treatment reports to a client’s insurance company or other concerned party by lawful and proper request. (p. 4)
Thus, as highlighted in the fourth case example earlier, no treatment may occur without documenting the services provided if one wishes to meet these ethical guidelines and legal requirements. But, just what should the clinician document and how should this be done? Although a variety of formats and styles exist for documentation, the specific method used should be driven by the clinical and ethical needs behind it. In other words, the clinician should keep in mind the purposes of the documentation when considering what and how to document. Several important clinical reasons exist for the thorough, accurate, and timely documentation of clinical services.
PROVIDING QUALITY TREATMENT
Most clinicians, even those only in part-time practice, lead very hectic and busy lives. Most have many obligations to attend to; numerous demands on their time, attention, and energy; and a number of patients’ treatments to remember. Even for those with excellent memories, remembering the details of all ongoing treatment cases would be difficult. Important information to remember so that competent ongoing care may be provided includes each patient’s presenting problems; relevant history; evaluation results; medical and health difficulties; significant mental status issues and changes over time; medications, doses, and side effects; treatment provided thus far to include interventions attempted and their outcome; homework assignments to follow up on in future treatment sessions; and working hypotheses to be followed up on as treatment progresses. For the busy clinician with an active caseload, it would seem impossible to meet ethical requirements to provide competent care without adequate documentation to review prior to each treatment session. As is highlighted by the fourth case example provided earlier, without such documentation, the provision of ongoing care in an ethical and competent manner would not be possible.
And what of patients who complete or for other reasons leave treatment? Mental health patients often return to their psychotherapist for further treatment, often months and even years later. Remembering all the pertinent clinical information after such periods of time is not possible for most. Considering such a scenario will help clinicians decide just what should be documented while treatment is being provided. Then, should a patient return for further treatment at a later date, the clinician will have records to review, a process that can greatly facilitate the patient’s reentry into treatment and the provision of quality treatment services.
Mental health patients who reenter treatment at a later date do not always return to the same counselor or psychotherapist. Numerous reasons for reentering treatment with a different clinician exist. These include dissatisfaction with the former therapist, a desire to try a new approach, a patient not progressing in treatment, changes in insurance coverage, the need for a different type of clinician such as one who can provide mediation as a part of treatment, and relocation to a different geographic area. What records might help the new clinician to provide quality services?Maintaining accurate records throughout treatment and drafting a treatment summary when treatment ends can greatly help facilitate the transfer to a new therapist or counselor. Such practices will also greatly assist the psychotherapist in responding to requests for treatment information from the new treating clinician.
Mental health professionals and consumers alike now live in a highly mobile society. Job transfers for these individuals and their spouses, seeking out new opportunities, and family obligations often necessitate that a clinician discontinue providing services to a client when further treatment is still needed. What information might the new psychotherapist or counselor need when accepting such a transfer so that a smooth transition may be made and excessive amounts of time not be wasted gathering information that might be readily available? The provision of a treatment summary upon transfer to a new clinician may help ease this transition and help ensure the patient’s needs are adequately being addressed.
As dedicated and committed as most counselors and psychotherapists are to their patients, it is neither possible nor recommended (watch out for burnout) that clinicians attempt to always be available for patient crises or emergencies. Most clinicians will take time off for personal replenishment and relaxation, go on vacations, attend continuing education programs and professional conferences, and at times be unavailable to patients because of illness or other personal obligations. For these reasons clinicians at times arrange for others to provide coverage for their patients when they are not available. What would the colleague providing this coverage need to know about each patient so that quality care might be provided? Considering this need when documenting services provided will also help ensure that patient treatment needs are adequately and ethically met during periods of therapist absence or unavailability, an issue addressed in the third case example stated earlier.
Similar issues are relevant for clinicians providing treatment to patients who are hospitalized. Clinicians cannot be available to treatment team members 24 hours each day. Patients may experience difficulties or crises during periods of therapist absence such as at night or over the weekend. What information would another clinician providing patient care during these periods of therapist absence need so that quality care may be provided? Contacting the psychotherapist is not always feasible or possible and being able to quickly review timely and pertinent information in the treatment record can be of vital importance. Thus there are a variety of ways in which counselors and psychotherapists help ensure their patients receive adequate care by timely, appropriate, and thorough documentation.
RISK MANAGEMENT ISSUES
There may also be times when a clinician must defend or justify the care provided to a patient, as illustrated by the first two case examples provided earlier. One very important use of documentation for clinicians is that it serves as a tangible record of what services were actually provided and helps demonstrate if the clinician is meeting the standard of care of the profession. With regard to legal proceedings and claims of negligence or malpractice, Bongar (1992) states: “In cases of malpractice, courts and juries often have been observed to operate on the simplistic principle that if it isn’t written down, it didn’t happen” (p. 24). Bennett et al. (1990) further add that “records can provide factual information on a case requiring evidence of meeting the standards of care” (p. 39). Without such documentation, the clinician is leaving matters up to chance. Thoughtful documentation will clearly indicate what treatment was offered, the patient’s level of cooperation and response to treatment, alternative treatment approaches considered, and the rationale behind any strategies or techniques used. Although clinicians cannot guarantee the outcome of treatment, the use of sound rationale consistent with the relevant standard of care which is documented can help address these needs. Slovenko (1979) points out, “an inadequate record of itself is taken to be indicative of poor care” (p. 418).
Also implied in this discussion is the role of effective documentation as a risk management strategy. Several authors (e.g., Soisson, VandeCreek, & Knapp, 1987; J. Sommers-Flanagan & R. Sommers-Flanagan, 1995) emphasize the important role of documentation and consultation for effective risk management. Guthiel (1990) further states that “good documentation provides a durable contemporaneous record, not only of what happened, but of the exercise of the mental health professional’s judgment, the risk benefit analysis, and the patient’s ability to participate in planning his or her own treatment” (p. 336).
As highlighted in the first case example provided earlier, when treating depressed and/or suicidal patients, documentation may take on increased importance. Bongar (1992) reports, “There is no substitute for a timely, thoughtful, and complete chart record that demonstrates (through clear and well-written assessment, review, and treatment notes) a knowledge of the epidemiology, risk factors, and treatment literature for the suicidal patient. Such case record also includes (where possible) a formal informed consent for treatment” (p. 25). Further, Jobes and Berman (1993) recommend that documentation with suicidal patients include specific ongoing documentation of each patient’s status including a self-assessment by the patient and the clinician’s assessment of risk. They stress that the use of ongoing documentation should demonstrate “adequate risk assessment and treatment planning, acceptable clinical follow-through, appropriate supervision/consultation” (p. 91).
Mental health clinicians, like all health care providers, function in an increasingly litigious environment. Because of the fear of litigation, some clinicians have reportedly taken a number of actions in an effort to reduce the likelihood of having to confront a malpractice suit. In one survey of clinicians (Wilbert & Fulero, 1988), the following reported changes to clinical practice were made as a result of the threat of litigation: keeping more thorough records, taking more seriously and evaluating more thoroughly the risk of suicide, and using additional assessment instruments to document clinical judgments. In light of the preceding discussions, these actions all seem appropriate practices for the prudent clinician.
MANAGED CARE AND DOCUMENTATION
For those clinicians who serve on managed care panels and work with insurance companies, the issue of documentation is very important. Many of these organizations require documentation for payment to be received. Practitioners are frequently required to share treatment information with utilization review personnel to justify treatment so that coverage of services rendered will be provided.
Clinicians will frequently receive requests for documentation to support utilization review decisions, to justify treatment decisions made and provide the rationale behind them, and to provide a tangible record of services provided which is often required to obtain ongoing authorization. In addition, as highlighted in the second case example provided earlier, there are times when the entire treatment record may be required for review by managed care personnel for authorization to be received.
As can be seen, for clinicians working within a managed care environment, maintaining adequate documentation of treatment services provided is of great importance. But, because the treatment record itself may be requested, clinicians may find it advisable to include only clinically relevant and necessary information in the treatment record. Information that is extraneous to a patient’s diagnosis and treatment should not be included in the record as others may have access to it.
DOCUMENTATION OF MARRIAGE, FAMILY, AND GROUP PSYCHOTHERAPY
When providing treatment to multiple individuals, whether couples, families, or groups, a potential dilemma arises concerning the fact that the release of records may at times be required by personal request, subpoena, or court order. If only one treatment record is maintained for all individuals involved in the treatment, the release of the record jeopardizes the other patients’ confidentiality.
In many states this situation is addressed through statutes. Thus, clinicians will need to maintain awareness of relevant state laws. In some jurisdictions clinicians keep a separate record for each participant in treatment so that others’ privacy is not intruded upon when one participant’s treatment records are disclosed. Although this is easy to do and a generally accepted practice for group psychotherapy patients, there is no uniform agreement among clinicians regarding marriage and family treatment. Knowledge of relevant statutes and sensitivity to the potential implications of actions taken are recommended.
CONTENT OF RECORDS
A number of reasons have been given for maintaining adequate, timely, and thorough documentation of all services provided. But what should be included or excluded from these records? Because of the sensitive nature of mental health treatment records, some care and forethought should occur when developing them. Suggested guidelines are provided on pages 8 to 15 for the appropriate documentation of initial evaluations and intake interviews (pp. 8-13), ongoing treatment sessions (p. 14), and treatment summaries (p. 15). It should be kept in mind that these are general guidelines which may be altered and adapted as particular situations and clinical needs may warrant. These guidelines are meant to assist the clinician and should not be a substitute for sound clinical judgment. Clinicians may have good reasons for adding or deleting information, depending on the unique circumstances of each case.
Because of the likelihood that the client and other parties may have access to these records, it is important, as Stromberg et al. (1988) recommend, that records be free of personal opinions, value judgments, and emotional statements. Rather, they should focus on statements of fact, behavioral observations, and a client’s report.
Thus, it would not be appropriate to document in a treatment record a statement such as: “During today’s session, Mr. Smith began the session whining and complaining about not receiving a promotion at work and continued his usual obnoxious and irritating behavior throughout the session.” A more appropriate documentation of these behaviors, if they are relevant to this patient’s treatment, would be: “Mr. Smith strongly expressed his feelings about being passed over for a promotion at work, stating ‘It’s so unfair, especially after all the hard work I’ve put in there.’ Positive actions he can take were explored and will be followed in later treatment sessions.”
When considering just how to document patient behaviors and statements as well as interactions with patients, Weiner and Wettstein (1993) recommend that “generally, specific observations about the patient are more useful to those who may review the record at some future time than the clinician’s impressions about the patient, which will be difficult to interpret” (p. 179). Soisson et al. (1987) further recommend that “information about illegal behavior, sexual practices, or other sensitive information that may embarrass or harm the client or others is rarely appropriate for the record” (p. 500). The general rule to follow is to consider who may have access to the treatment record at some later date and prepare your documentation accordingly. Materials and information not directly relevant to the client’s treatment, which do not add to the clinician’s ability to provide quality care, and which hold the potential to be embarrassing or harmful if released, should not be included in the treatment record. In these days of increasing access to treatment records, assuming the assurance of absolute confidentiality is inappropriate. At best, only relative confidentiality can be anticipated (Miller & Thelen, 1986).
Additionally, to ensure that the standard of care is being met, as a risk management strategy, and as a means of protection against successful malpractice litigation, clinicians will generally seek out supervision or consultation from colleagues with experience and expertise in the clinical domain in question. It is equally important that the psychotherapist document these consultations detailing the issues discussed, the reasons why, recommendations made, actions taken, and the outcome.
INFORMED CONSENT
All counselors and psychotherapists will want to ensure attention to the ethical and legal doc trines of informed consent. Prior to entering into a treatment relationship, an agreement should be reached between the two parties which stipulates the parameters of the professional relationship. Although a detailed discussion of informed consent is beyond the scope of this contribution, the thoughtful clinician will have a written record of all treatment contracts and agreements. In general, such agreements should include the names of the parties, the schedule of treatment meetings, fees and financial arrangements to include billing policies and charges for missed appointments, the use and limits to the use of insurance, any insurance or managed care requirements, the limits of confidentiality and potential reasons for breaching confidentiality, the use of audio- and videotaping, mechanisms for responding to crises and emergencies as well as for contacting the therapist between appointments, the treatment plan, the rationale behind it, and any risks and benefits involved and alternatives available. Further, if changes are to occur in any of these areas, they should first be discussed with the client and then the new agreement should be documented. Although some clinicians utilize written contracts and treatment agreements (examples may be found in Callahan, 1989; Kachorek, 1990) it is important that these issues be discussed to ensure each client’s full understanding. This discussion should be documented and the treatment agreement signed by the client and maintained as a part of the treatment record to avoid any future misunderstandings.
RECORD STORAGE,RETENTION, AND DISPOSAL
Counselors and psychotherapists who maintain treatment records as has been discussed are confronted by the issues of record storage, retention, and disposal. Guidelines for record storage are provided in each mental health profession’s ethics code, all of which require that the client’s right to confidentiality be protected when attending to record storage. Treatment notes and files should not be left in areas where unauthorized persons will have access to them. Thus, leaving treatment records out on one’s desk overnight where housekeeping or maintenance personnel may view them is considered inappropriate. Records should be stored in locked file cabinets so that unauthorized access is avoided and patient confidentiality is preserved.
For those clinicians who use a computer to record documentation, similar precautions are necessary to preserve client confidentiality. The use of passwords, encryption of data entries, and keeping computer disks in locked storage will help ensure confidentiality. It is also important not to keep confidential information in a hard drive where others might have access to it. When erasing disks, Susskind (1989) cautions that “a moderately sophisticated user can restore and read files that have been erased, even after a disk has been reformatted” (p. 12). As a result, he recommends the use of software that “wipes” a file or disk by printing random characters in place of the original text, thus protecting confidentiality. Regardless of the medium used, the clinician is responsible for taking adequate precautions to ensure that inadvertent or unauthorized disclosures of confidential materials do not occur.
As has been mentioned earlier, clients who complete treatment may return for further treatment at a later date; the maintenance of treatment records over time may ease the client’s return to treatment. But for how long should treatment records be retained? Clinicians should be aware of guidelines in their ethics code as well as relevant state laws. For example, psychologists are guided by their Record Keeping Guidelines (American Psychological Association, 1993) to retain treatment records “for a minimum of 3 years after the last contact with the client. Records, or a summary, are then maintained for an additional 12 years before disposal. If the client is a minor, the record period is extended until 3 years after the age of majority” (p. 985). These time requirements are extended, if necessary, to comply with relevant statutes.
Typically, counselors and psychotherapists will have neither the storage capacity nor the inclination to retain all treatment records indefinitely. Thus, when the time limits for record retention have been exceeded, records may be disposed of in an appropriate manner. Again, attention to preserving client confidentiality is of great importance. Merely discarding obsolete treatment records in the trash leaves them very vulnerable for discovery and review by others, thus violating the client’s privacy. Stromberg et al. (1988) recommend that records not simply be placed in the trash, because methods of trash collection and disposal can be haphazard and can result in confidential materials being seen by others. Instead, it is recommended that records be shredded or otherwise destroyed.
CONCLUSIONS
Documentation serves several important roles in the provision of mental health services. By keeping accurate, timely, and relevant documentation, counselors and psychotherapists will help ensure that they provide treatment in an ethical and competent manner. This practice will be valuable as a risk management strategy, help guard against successful malpractice litigation, be of assistance if clients reenter treatment at a later date, and help to provide appropriate care in the clinician’s absence. Although adhering to relevant statutes and ethical guidelines is important, the paramount issues behind appropriate documentation are the clinician’s efforts to meet the highest standards of the mental health professions and the desire to best meet each mental health client’s treatment needs.
Outlines of suggested formats for documentation of clinical services are provided on the following pages.
INITIAL EVALUATION/INTAKE INTERVIEW
Current Problem:
Psychiatric History:
Medical History:
Birth, Childhood, and Development:
Significant Events/Memories:
Traumas/Abuse:
Childhood Fears:
Social Functioning:
Family Relocations/Reactions:
Overall Impression of Childhood:
Educational History:
Employment History (if Applicable):
Social History:
Substance Abuse History:
Legal History:
Sexual History:
Family History:
Self-Perception and Goals:
Significant Recent Trauma/Stressors:
Mental Status Examination:
Behavioral Observations:
Diagnostic Impression:
Treatment Plan:
Informed Consent/Treatment Agreements:
Issues to Follow Up on:
DOCUMENTATION OFTREATMENT SESSIONS
Time of Session and Time Note Was Written if at a Different Time:
Changes in Client’s Condition/Progress Observed/Difficulties Experienced:
Response to Treatment Interventions:
Level of Cooperation:
Medical, Health, Other Difficulties – Actions Taken/Referrals Made:
Interventions Used/Clinician’s Rationale – Decision-Making Process/Goals:
Consultations/Supervision With Others:
Contacts With Others/Telephone Calls, and so on:
Changes in Mental Status:
Risk Management Strategies Utilized (e.g., Suicide Contract):
Date and Time of Next Appointment:
TREATMENT SUMMARY
Summary of Mental Health History:
Date First Seen:
Reason for Contact and Referral Source:
Length of Treatment and Date of Completion:
Course of Treatment:
Jeffrey E. Barnett, PsyD, is a licensed psychologist who received his degree from Yeshiva University in 1984. He maintains a private practice in Annapolis, Maryland and is a Clinical Associate Professor in the Department of Psychiatry at the University of Maryland School of Medicine. He is also an Adjunct Associate Professor of Psychology at Loyola College in Maryland. He lectures and writes frequently in the areas of legal and ethical issues in professional practice. Dr. Barnett is a past ethics committee chair and past president of the Maryland Psychological Association. Dr. Barnett may be contacted at 8 Willow Street, Annapolis, MD 21401.
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