Simply put, good records benefit the client, the clinician, the agency, and the profession. They “serve and protect all parties.” Content of Documentation Good documentation requires organization, decision making, critical conceptualization, and effective writing. Good clinical documentation has specific elements of organization and writing (Bodek, 2010). According to Kagle and Kopels (2008), good clinical records will demonstrate these 15 principles: 1. Balance - of the valued but competing goals of accountability, practice improvements, efficiency, and client privacy 2. Focus on the mission - with content relevant to the agency mission or program objectives 3. Risk management - achieved by good compliance with agency policy, legal standards, practice guidelines, and professional ethics 4. Accountability - with a focus on service delivery, impact, and outcome 5. Abridgement - exclusion of information that is not pertinent to purpose, goals, or outcome of service 6. Objectivity - presentation of information that is fair and impartial and that includes observation, sources of information, criteria used in assessment, and appraisal 7. Client involvement - documentation of the client’s role in all aspects of the process 8. Sources - provision of sources for all information 9. Cultural context - inclusion of cultural factors influencing the client’s situation or service 10. Access - information written with the assumption that anyone may have access to it 11. Usability - organization of records, usually chronologically, in a reader-friendly way 12. Currency - records kept current with periodic reviews and updates 13. Rationale - provided for all service decisions 14. Urgent situations - full documentation of emergencies or crises 15. Exclusions - of irrelevant, extraneous, opinionated, or speculative information The minimally required content for good clinical documentation in a case record would include agency-specific templates and formats, such as documentation of informed consent and confidentiality limits, case notes, assessments, and diagnostic codes. Sometimes organizations provide templates for certain parts of a case record (e.g., consents, releases of information, assessments) to increase the uniformity of the record; however, the quality of case notes in particular is largely dependent upon the individual clinician’s skill in documentation apart from their interviewing skills and ability to elicit the information that is necessary and relevant to the therapy. Discerning what is sufficient, necessary, and relevant to document is as much a practitioner skill as learning therapeutic techniques. The clinician’s interpretation of information to document, and the method by which to document it, determines the quality of the documentation. Practitioners should document with the Overall Chart Organization Chart organization and content may differ across settings. Organizations can require specific and structured information, whereas private practitioners have more flexibility as to order and organization. Bodek (2010) provides a framework for organizing a patient record for healthcare settings and advises that a file folder exclusive to each patient be maintained. The folder would consist of: ● Demographic information, including insurance and referral information ● Intake information, including assessment, evaluation, and initial history ● Service or treatment plan ● Progress notes
expectation that a much wider audience than expected may read what is written. The content of excellent clinical documentation provides insight into client needs, justifies and chronicles the course of intervention, and demonstrates progress and outcomes. Mitchell (2007) takes the viewpoint of charting for the reader. He proposes basic principles to create a useful record for colleagues and clients. ● Language should be clear and specific, avoiding irrelevant statements or excess verbiage. ● Whenever possible, the client’s own words should be used. Write what is heard. ● Write what could be comfortably shared with the client. ● Write records logically. Ensure that charting has some relevance to the presenting problem or the guiding treatment plan. If charted information is not pertinent to either, it should not be included. “Usefulness requires specificity, and vague writing might be construed as indicating incompetence” (p. 31). ● Avoid modifiers (such as soon or sometime) that are abstract or could leave room for doubt. Ultimately, according to Mitchell (2007), records should be understandable and accountable. Although HIPAA does not specify what is required in a medical record, according to Groshong and Philips (2015), the following must be included to meet behavioral health guidelines. ● Billing information and payment records ● Formal evaluations ● Collateral contacts, including release of information (ROI) for all ● Records from other providers with ROI ● Counseling session dates, with start and stop times ● Modalities and frequency of treatment ● Medications ● Diagnoses ● Functional status (activities of daily living [ADL], ability to work, interpersonal capacity) ● Medical/physical problems ● Community contacts, including phone calls, emails, or texts ● Treatment plan and goals ● Symptoms and prognosis ● Progress in each session ● Disclosure forms and informed consents signed by licensed professional and client ● Presenting problem(s) or purpose of visit ● Referrals to and results of formal consults ● Progress notes sufficient to support responsible clinical practice for the type of orientation/therapy used All digital medical records should be backed up regularly and kept in encrypted format, with frequent changes in passwords. Although there can be both medical record and psychotherapy notes, information cannot be put in psychotherapy notes to avoid putting it in the medical record (Groshong & Phillips 2015). ● Referrals or consultations made, collateral reports, and test results ● Correspondence from other practitioners ● Correspondence with patient or collaterals ● Billing records ● Informed consents/authorizations or other privacy-related information releases Consents and authorizations do expire, so records should contain original and updated forms so that the history of consent to services, communications, and such is evident (Hoffman & Herveg, 2021). In addition, it is recommended that a Health Insurance Privacy and Accountability Act (HIPAA) compliance
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