INTRODUCTION
Proper documentation is based on the standard of accountability. Too many clinicians receive minimal training in this area, despite its central role in behavioral health practice (Reamer, 2009; Sidell, 2015). The lack of knowledge and skill regarding documentation is a potential liability. Documenting according to ethical standards is therefore relevant to all clinicians. With technological advances, digital documentation has increasingly become the norm; however, electronic health records and other forms of electronic communication pose ethical risks in documenting services. For social workers, counselors, marriage and family therapists, and psychologists, documentation is equally important before, during, and after a clinical encounter. A common adage states: “If it isn’t written, it didn’t happen.” Although documentation serves multiple essential purposes, it is fraught with risk and liability. Sidell (2015) advises that proper documentation is one way to protect clients, practitioners, and the organization. Kadushin (1972), a pioneer who authored seminal works on the mental health encounter, suggests that “the interview begins before it starts” (p. 106), meaning that clinicians often formulate impressions and speculations about clients or patients before they ever speak to them in person. For example, paperwork is often completed by an intake or clerical staff worker long before the clinician actually meets with clients in person for the first time. This preliminary documentation may direct the assessment and treatment process. What is written about the client may appropriately assist the practitioner, or conversely, it may provide a detour from providing the best treatment. Imagine that a medical technician inaccurately records a patient’s blood pressure and that the patient is put on medication for hypertension unnecessarily, has a reaction to the medication, and dies. In response to the tragedy of an unnecessary death, the family sues the practitioner and practice agency; as a result, several lives are changed forever. Although this example is an extreme worst-case scenario, equally harmful documentation missteps are possible in the behavioral health field. A social worker on a specialty cardiac unit speaks with a client who is tethered to a left ventricular assistive device (LVAD) while waiting for a transplant. In her attempt to be accurate in documenting their conversation, she charted the client’s exact words: “Sometimes I just want to pull the plug.” She continued to assess for suicide and deemed that the patient was not in imminent risk but just feeling understandably discouraged sometimes. She charted, “We processed his emotions and ambivalence living with an LVAD.” When other team members read her note, a psychiatric emergency evaluation was arranged, which upset the patient even more. He told the social worker, “You knew what I meant. I wasn’t going to kill myself. I will never confide in you again!” What might she have done differently to avoid the upsetting response to her documentation? She had the option of not recording the client’s exact words and charting more about exploring his discouragement and frustration. She could have included more about her suicide assessment and her conviction that he was not a danger to himself. So, in this instance, either
documenting more or documenting less could have influenced the outcome considerably. Practitioners usually know what is minimally required in documentation; however, what is least required may differ significantly from what is recommended or optimal. Optimal documentation includes information that is relevant to the clinical services being provided and that addresses legal, ethical, and administrative obligations. Agency practice and time demands often result in practitioners documenting only what is required. This practice may leave the agency and practitioner open to scrutiny and risk, and at the same time shortchange the client’s services. This basic-level course will help practitioners approach documentation in a way that is guided not solely by what is mandated, but by what is mutually beneficial to all stakeholders in the documentation process: The practitioner, the agency, the funding source, and - most of all - the clients. Graduate training rarely includes course content on documentation skills (Leon & Pepe, 2013). Sidell (2015) recommends that behavioral health professionals begin their careers well prepared to document, but often they do not. Historically, only six texts were written about case documentation from 1920 to 2008, and limited attention is given to it in practice texts (Sidell, 2015). Although graduate education requires that the field placement or practicum experience teach documentation skills, documentation requirements may differ according to the agency setting and may or may not be equally applicable across professional settings and roles. Often practitioners are left to learn the complexities of appropriate documentation on the job, and their work is often supervised by individuals with perhaps limited training on documentation. Leon and Pepe (2013) suggest that one way to close this gap is to provide more continuing education workshops that help to “develop and maintain those essential skills” (p. 116). This will be discussed later in this course. Their study on the effects of a two-part continuing education documentation workshop for hospital psychosocial staff members showed a significant increase in staff knowledge of documentation in the areas of progress notes and discharge summaries. The authors point out the scarcity of research on reliable and valid documentation measures and underscore the need for more continuing education and research in this area. Based on their evaluation of a documentation workshop, Dziegielewski and Holliman (2019) also demonstrated a need to train individuals in all disciplines on issues of documentation regardless of their professional license. To help fill the void in training on documentation found by several authors, this course illuminates the complex nuances of writing for the clinical record and assists the practitioner in determining when, what, and how much to document. In addition, summaries related to documentation from the codes of ethics of the American Association of Marriage and Family Therapy (AAMFT), the American Counseling Association (ACA), the American Psychological Association (APA), the National Association of Social Workers (NASW), and National Board for Certified Counselors (NBCC) are included in the Appendix.
THE RATIONALE FOR DOCUMENTATION
Frederic G. Reamer (2009), one of the architects of the current NASW code of ethics, describes documentation as one of the most important skills in behavioral health practice. The clinical need for thorough, accurate, and timely documentation to ensure quality service delivery cannot be overemphasized. In addition, given the growing demands of managed care and utilization review, documentation is increasingly more important in healthcare settings as accountability, clinical accuracy, and treatment outcomes determine funding and the level of authorized services. The NASW Code of Ethics (2017a) reflects the impact of swift technological change on practice,
including treatment options as well as storing, retrieving, and documenting client data, particularly in electronic health records. The vignettes included in this course are designed to illustrate many of the reasons for good clinical documentation, as well as some of the ethical risks, fears, mistakes, and myths of documenting in the helping professions. What drives documentation? Who is it for? Whose interest does it serve? Record keeping is a safeguard for both practitioners and clients. Good clinical documentation primarily meets the needs of the client, practitioner, and agency; however, it is also intended to meet the needs of the supervisor, professional boards, regulatory organizations, and accrediting bodies. O’Rourke (2010) provides
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