P – Continue to meet with Samantha weekly to prepare for the upcoming reunification, fortify stress management, social, and parenting skills. How did Darlene navigate the various confidentiality concerns in this progress note? Confidentiality was protected with no identifying information about collaterals disclosed. The language is not harming, discriminatory, or judgmental, with a tone of identifying progress and strengths. Wiger (2022) outlines common problems with progress notes, including vagueness, irrelevant information, and inability to elicit essential information from uncooperative clients, all of Information from Others Documenting information received from collateral contacts varies according to the purpose of the information and the manner and setting in which it is received. Likewise, child custody evaluations and investigations of domestic violence rely on third-party information (Henry, 2018). Documenting third- party information is a significant aspect of clinical record keeping in these situations. Parents or other caregivers are almost always involved in coordinating a child’s care in terms of scheduling appointments or coordinating with other providers. All of these contacts must also be recorded in a client’s record. Clinicians will also encounter collateral information under less life-altering circumstances, however. For example, a relative of a client leaves a voicemail for the therapist providing unsolicited, potentially important, possibly damaging, information. Is it necessary for the clinician to document anything? The decision concerning whether to document material received by collateral informants is based on clinical, legal, and therapeutic determinants. In some instances the information may be clinically important, and the information could have potential legal implications. The therapist’s records could be involved if there is a civil suit. One might be tempted to ignore the unsolicited information. However, not discussing Case Study 3 Used nondirective play therapy with Josh today. His drawings indicate isolation and reclusiveness and never include his mother, who one would expect might be present in the pictures to represent security. After meeting with mother today, it is understandable that Josh doesn’t have her in his pictures as she seems to have her own anxiety issues and Josh gets easily agitated around her. What is potentially harmful about this note? It may be clinically correct that Josh’s separation anxiety is connected to his attachment with his mother, and it is generally accepted that mothers provide security to children. Therefore, the comment “who one would expect might be present in the pictures to represent security” might be acceptable. However, if Josh is the client, should the clinician be giving a diagnostic impression of the mother, as in “she seems to have her own anxiety issues”? The clinician is making an evaluative statement without any corroborating information. Unnecessary information increases liability risk, as irrelevant information may breach client privacy. What might go wrong as a result of this documentation, even if it is true that the mother has been diagnosed with or treated for anxiety? The mother might say, “Well, I’ve been treated for anxiety myself, so it’s no wonder Josh has problems.” This information may be relevant to Josh’s condition in that his own anxiety is both learned and inherited, but it is important for the clinician to ask themselves if it is necessary to document the statement and if documenting it could be a risk. In fact, it is not necessary to document the statement. Furthermore, documenting it could indeed be a risk. What if the pediatrician, school personnel, or another therapist reads the record? What if the father, in a custody dispute, subpoenas the records and uses the comment about the mother to prove she is not fit to
which can lead to ethical issues. In addition, taking shortcuts in documentation, such as not charting a separate note for each member attending a group or family therapy session, can be problematic. A simple framework for objectively assessing clinical notes is that another reader should be able to answer the following questions (Martha St. Enterprises, Inc., 2009): ● What brought the client to seek help? ● What was done about that presenting problem? ● What were the interventions and results? ● What was the disposition? or documenting the call also carries risk. To cover all bases, it would be prudent for the therapist, first, to recognize that she does not have a duty to keep the grandmother’s disclosure confidential. If the grandmother had spoken directly to the therapist rather than leaving a message, the therapist could have advised the grandmother that her disclosure is not confidential. In addition, without the consent of the client, the therapist can neither confirm nor deny that her grandson is a client. Next, the therapist should discuss the phone call with her client and document the results of that discussion. The therapist is then in a better position to assess the reliability of the information, its potential significance for the therapeutic work, and liability risk. Unnecessary Information Kane (2002, p. 56) states that documentation should be: ● Accurate and helpful ● Thorough and complete
● Legible ● Timely ● Without editorializing comments
Editorializing comments may be the most concerning for liability purposes. Consider this progress note of a clinician treating an 11-year-old boy for separation anxiety.
have custody? One clinical statement, although likely to be true, has gone terribly awry. The mother’s privacy has been violated. Reamer (2009) suggests that such editorializing is tantamount to defamation of character and potential grounds for malpractice or litigation. Information included in records should not be gratuitous or extraneous to the situation. Standard 3.04 of the NASW Code of Ethics counsels that documentation must be accurate, timely, and reflective of services provided, as well as protective of client privacy. This can be accomplished by recording only information that is “directly relevant to the delivery of services” (NASW, 2017a). Moline and colleagues (1998) describe the minimum and maximum content criteria for treatment records, including what not to document or keep in the file. Material that might prove embarrassing to the client or to the therapist is best not included in documentation, including information that might easily be misinterpreted by another reader. Such information might include personal opinions, discussion about a third party (hearsay), sensitive information that is irrelevant, specific information about client family members, or past criminal behavior. Mental health practitioners who are self-employed as consultants or work independently in private practice should keep case notes, although these notes are not subject to agency or supervisory scrutiny. Independent practitioners should adhere to guidelines established by the state regulatory body in which they are licensed and/or their professional organization. The record is “written for different purposes and different readerships, which results in competing tensions in its construction” (O’Rourke, 2010, p. 125). In sum, regardless of the setting, recording is a demanding task in the delivery of clinical services.
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