Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
25. The mother of a 14-year-old client texts the therapist and says the client is having a bad week. The mother had asked the child’s pediatrician to prescribe medication, but the doctor wants to talk to the therapist first. State laws stipulate that only children 14 years old and older have confidentiality rights. The therapist should: A) Document the mother’s text and send a text to the pediatrician. B) Refuse to discuss the client’s treatment, citing confidentiality. C) Text the mother back, stating that the therapist will not communicate via text. D) Document the text and get a signed release for the pediatrician from the mother and client. 26. A practitioner is seeing a woman for depression and anxiety symptoms. Between sessions, the practitioner receives a voice message from the woman’s husband, who reports that the client is probably not telling the worker the “whole truth” and reveals that the client has a significant alcohol use problem. What should the practitioner do about documenting this information? A) Discuss the phone call with the client at her next session and then document the discussion. B) Nothing. The practitioner should ignore it in both the client’s session and the documentation. C) Keep notes about the information in the voicemail in a personal or shadow file. D) Immediately call the husband back and document the phone call in the file. 27. Documenting unnecessary information may breach client privacy. Which of the following is an example of unnecessary information in the context of individual therapy? A) Specific information about a client’s family member. B) The therapist’s reactions and response to the client’s behavior. C) The client’s report of her symptoms. D) The client’s medical history. 28. Documenting opinions, facts, or sensitive information about a third party may be considered: A) The most important part of a client’s record and necessary for good therapy. B) Defamation of character and grounds for litigation against a therapist. C) Irrelevant information, but necessary for a complete biopsychosocial assessment. D) A breach of confidentiality only in the context of couple’s therapy.
29. Even if state law stipulates that clinical records must be retained for a specific time, clinicians might consider storing records indefinitely because: A) Different professions have different regulations. B) An injured party can file suit decades after alleged malpractice. C) The client may want to come back for service years later. D) Old records are often used for training novice practitioners. 30. Trying to streamline record keeping in a psychiatric inpatient unit, clinicians providing group therapy write one generic note, copying it to each patient’s chart. This practice is an ethical violation because the: A) Information about group therapy is unnecessary. B) Documentation is inaccurate and incomplete. C) Group members are often editorializing. D) Funding source may want more information. 31. Henry provides administrative and clinical supervision to several mental health practitioners. Susan, one of Henry’s supervisees, does great clinical work but is consistently late in documentation. She was placed on a performance improvement plan that did not yield positive results. During her performance review, Susan protests that she is bringing in the most revenue from clients and is known as one of the best clinicians in the agency. She doesn’t understand how late documentation could be any more important than clinical effectiveness and bringing in money! Henry’s most appropriate response would be to tell Susan that: A) If it isn’t written, it didn’t happen. B) She is putting clients, the agency, and her own reputation at risk. C) If she died tomorrow, nobody would know what was happening with her clients. D) She cannot get a bonus if she is unable to prove what she does. 32. Some behavioral professionals disagree on the validity of diagnostic codes for children because: A) The ICD and DSM models are too categorical, omitting client criteria that exist in a continuum of behavior and circumstances.
B) Payers refuse to reimburse for family therapy. C) Psychiatry, psychotherapy, and social work are professionally at odds with one another. D) Providers prefer clear, concise diagnostic coding.
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