The patient health record is the singular place where all relevant and necessary health data exist. Behavioral providers serve the patient in recording only relevant data about the patient, excluding the unnecessary. Serving the patient in this way, the provider also serves the treatment team, providing the critical behavioral information that will elucidate the necessary behavioral health concerns for other health providers. Working in integrated care is a balancing act—serving patient needs and the remainder of the treatment team simultaneously requires professional flexibility, practicing effectively for patients and for other providers on the treatment team (Cairns et al., 2018). The researchers interviewed various healthcare professionals, including behavioral providers, inquiring about their documentation practices, especially from the lens of ethical practice. Providers indicated that withholding sensitive information from the health record is an ethical compromise that hinders facilitating a positive relationship with the patient and the provision of overall appropriate care. According to interviewed providers, sensitive information that might be withheld includes intricate details of traumatic events, extreme descriptions of emotional states, inappropriate behaviors, and fraud. Other providers indicated being hesitant when creating the patient record for fear of creating an accidental prejudice or
negative attitude in the minds of other providers towards the patient (Cairns et al., 2018). Furthermore, providers identified that they attempted to avoid the use of judgmental language, favoring neutral descriptions of patients so as to protect against unnecessary bias toward the patient. One provider that was interviewed put it this way: “I always review notes. . . . And I have read clinical notes that have been recorded in a way that makes me cringe, because of implied judgements. I can’t control how other colleagues choose to record, what I can make sure is that what I record is accurate and reflects. And if it is an opinion, it’s stated as an opinion and not a fact” (Cairns et al., 2018, p. 359). An additional contextual concern raised by the authors is the presence of tension between various healthcare providers and how patient information might be misused or misunderstood within the healthcare organization (Liew, 2012). This potential or real unease, the authors report, can be characterized by several pertinent questions such as “might one’s records be misinterpreted or misused by others unschooled in the norms informing them? Might clients feel betrayed by sharing across professional boundaries? Such concerns are present in the literature, but how they impact upon providers’ perceptions of the ethics and their practice of recording is not fully understood” (Cairns et al., 2018, p. 352). disorder. Research narratives could then isolate key differences between the two clinical groups, providing a rich observational view for publication (Harris et al., 2009). Additionally, authors suggest furthering this research approach by requesting input from legal professionals who could comment on risks that could emerge from violations within various case records. Training and education can also enhance a clinician’s understanding of ethical and legal case documentation. Graduate programs in social work, marriage and family therapy, mental health counseling, and counseling psychology can greatly assist in this process by reviewing and revising, if necessary, their curricula to include coursework on state-level ethical and legal requirements for case documentation. If current graduate coursework is insufficient in this area, Harris and colleagues (2009) write that “students can be trained in case documentation within the classroom setting. Courses that focus on professional development, ethical, and legal issues, or clinical practices and procedures could all touch on clinical records” (p. 395). Supervisors can offer ongoing, weekly training sessions for new clinicians to help them understand practical requirements that must be met when creating a proper case record. However, supervisors may be deficient themselves in the knowledge required to adequately train in this manner. If this is the case, supervisors may be an important first group to evaluate for competency related to proper documentation practices. Additionally, legal professionals and seasoned providers can be contacted to organize potential training sessions to address statutory requirements and ethical precepts that new clinicians must observe (Harris et al., 2009). From marketing a practice on a website to using avatars in counseling, the use of digital technology and social media has changed the face of the counseling profession. Frederic G. Reamer, quoted in Pace (2014, p. 4), suggests that the use of technology “fundamentally alters the helping relationship.” He has researched the ethical challenges that can result from new interventions such as telehealth, email chat, social networking, texting, phone apps, and self-directed web- based healing modalities, going so far as to suggest that it is not inconceivable that a practitioner may never see a client in person (Reamer, 2013). Documenting services provided online or via telephone and clients’ access to such documentation have
Future Considerations: Documentation Research and Training Ideas Researchers have pointed out that academic research in the area of behavioral documentation seems to be conspicuously lacking, despite given the multifaceted importance of properly written and maintained clinical records (Harris et al., 2009; Jay et al., 2022). The call has been made for more peer-reviewed empirical research and writing in this area; however, certain barriers to research exist, namely, the crucial factor “that case notes are to be kept confidential. As such, a close scrutiny of any case notes, even from an objective research-oriented perspective, would be difficult” (Harris et al., 2009, p. 381). Behavioral healthcare leaders, graduate-level educators, clinical researchers, professional trainers, and clinicians can all benefit from ongoing research and continuing education in this domain (Brintzenhofeszoc et al., 2019).
One suggestion is that a Delphi study method be undertaken to interview behavioral professionals who occupy positions on state licensing boards, particularly those who review ethical complaints against clinicians. In this type of potential study, researchers could compile expert opinions on the role that documentation plays in ethical complaints that result in penalties, without revealing protected health information, thus preserving the confidentiality of clients and patients (Harris et al., 2009). Another study recommendation is that a clinical scenario could be presented in a video format to a group of experienced clinicians and a group of newly licensed providers. Given this scenario, clinical documentation of the vignetter could be thus studied and compared along key observational points within the clinical records, such as assessments for suicidal ideation, homicidal ideation, or the presence of posttraumatic stress Documentation and Patient Care in a Digital World Mental health practitioners are increasingly making use of various forms of digital technology in their professional work from electronic health records, texting, telehealth, and online delivery of services, with advocates pushing for an expansion of technology to create greater access for patients (Magnavita, 2018; Maniss & Pruit, 2018). The American Psychological Association (APA) recognized that technology would change so quickly that references to specific forms of technology might have to be revised frequently. Thus, the choice was made to eliminate specific references in favor of broad-based terms and suggestions for security and protecting confidentiality, such as maintaining a separate psychotherapy note in an electronic health record.
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