All records should be stored in a locked location that is accessible only to those with a need to know. Electronic records need additional security precautions. These security precautions include password-protected computers and, for added protection, the storing of records on computer drives not linked to the Internet. Keeping records of deceased clients is important, as they could be helpful in potential litigation. It is prudent to be familiar with federal statutes regarding records, such as HIPAA and the drug and alcohol use confidentiality regulations (the Code of Federal Regulations, Title 42, Part 2, A client is being seen for erratic behavior, including angry o utbursts. The therapist documents that his diagnosis is undetermined, that there is a family history of diagnosed schizophrenia-spectrum and other psychotic disorders, and the following clause is in the chart: “Client reports a previous psychiatrist diagnosed him with schizophrenia.” At a later date, the client requests his records and when he sees this notation about a schizophrenia diagnosis demands that it be stricken from the record. He does not want any mention of schizophrenia in his chart. What does the therapist do? Is altering records risky? Could it be construed as fraud? There is a difference between altering records and correcting records (Zur, 2018). Reasons for correcting records include mistaken notations regarding any part of the charting, including assessment, diagnosis, client behavior, therapist intervention, plans, wrong words, or terms. Clearly, corrections are justified in these instances because it is in the best interest of the client. Accuracy is crucial in providing and maintaining appropriate service delivery. Inaccurate records can result in litigation against clients, therapists, or affected third parties. Altering Records Case Study 6 However, if a client requests an amendment or change to the record, is doing so justified? The answer is: Only if there is a compelling and valid reason to do so. Imagine a therapist gets a court-ordered subpoena to turn over records on a client. She reviews the record and notices several comments that are potentially damaging for the client to retain custody of her child. The therapist removes these comments such that the original record is illegible. Or the notes are redacted without any indication as to why. This action could be deemed to be inconsistent with the standard of care of documentation, in addition to being unethical and possibly illegal—a type of fraud through omission or concealment. With today’s forensic technology and timestamping of EHRs, records that have been changed, by hand or electronically, can easily be detected. In the same scenario, as the therapist reviews the record before complying with the subpoena she notices that she got an important detail wrong in the assessment because she misunderstood at the time regarding the family constellation. In this instance not only does she have the right to correct the information, but perhaps also the obligation to do so. How to correct a record is typically not standardized. Often, consulting an organization’s legal department is a common way to determine the necessary steps for addressing corrections to a record. Strikethroughs with initials is one way and providing a dated amendment to an asterisked section is another. Documenting the reasons for the change provides support and an explanation for the clinician’s actions In the scenario regarding the client’s demand that any reference to schizophrenia be deleted, is there a compelling reason to agree to the client’s request? It could be argued that the therapeutic alliance and the client’s peace of mind could be threatened if the request is not met. But if the information is deleted, the therapist must explain why. Did she make a mistake? Was the information inaccurate? The simple answer is no. Noting that the client had reported a previous diagnosis
of the Code of Federal Regulations [42 C.F.R. Part 2], known as 42 CFR Part 2, or “Part 2”), and with state laws and regulations pertaining to records (e.g., storage, retention, client access; Pace, 2014) as well as federal law governing public health (U.S. Code, Title 42, §§290dd-2 [1992]). The above-mentioned federal statutes that implement these drug and alcohol use confidentiality regulations guarantee the strict confidentiality of information about all persons receiving substance abuse prevention and treatment services.
of schizophrenia by a psychiatrist and that there is a family history of the illness are both relevant to the client’s care and pertinent to maintaining a complete record. In this instance documenting the client’s reaction to seeing his records and his request to remove information may be the most appropriate course of action. In reality, the therapist in this case did delete the information, leaving a blackened space with a notation that it was at the request of the client after seeing his records. Future providers or third parties reading that record are sure to be The NASW Code of Ethics (2017a) specifically addresses ethical breaches regarding documentation and client records. Standard 4.04 speaks to dishonesty, fraud, and deception. Documentation is one area in which dishonesty, fraud, and deception might occur. Clinicians must document only that which is true. Embellishing symptoms to ensure insurance reimbursement is an example of a “white lie” that a practitioner might argue is necessary to secure needed services. The risk is high. Reamer (2009) suggests that the slippery slope begins when providers, out of a sense of altruism, exaggerate needs to procure mystified about what was redacted. Service Reimbursement or Extension reimbursement or falsely bill under a family member’s insurance to extend services. In addition, more blatant forms of deception in documentation exist in exaggerated or misleading claims of effectiveness, falsified records, and deliberate fraudulent insurance submissions, such as documenting and billing for individual sessions for each person seen in a group. Kane and colleagues (2008) describe the challenges of documentation in a managed care environment. With managed care, emphasis is on limited services that are brief, cost-effective, and empirically based. It is a “pragmatic, medical model derived approach to intervention. Based on cost, need, the outcome of service, and rigorous documentation [italics added], providers are reimbursed” (p. 200). An ethical challenge for providers is that the rigorous documentation called for relies on a pathology focus, which is in direct opposition to empowerment and the strengths-based approaches inherent in humanistic counseling intervention. Providers finds themselves in a position in which a focus on deficits may determine continued service and reimbursement. The ethical risk of overstating a problem with the altruistic goal of securing service for the client is evident (Gursansky et al., 2020). Ethical breaches can be inadvertent mistakes, such as leaving a file open on a computer or a paper chart open on a desk where someone can view it. This type of violation is represented legally as “misfeasance”. Documentation mistakes might be found in records that contain unintentionally inaccurate or incomplete information or improper storage of records (misfeasance), knowingly recorded false information (malfeasance), or absence of required information such as an informed consent (nonfeasance). The following scenario was presented by a therapist in a large private practice.
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Book Code: PYFL4024
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