Record keeping State statutes, contracts with state agencies, accreditation bodies, and other relevant stakeholders prescribe the minimum number of years records should be kept. For example, HIPAA has a requirement of six years for electronic records. The NASW Insurance Trust actually strongly recommends retaining clinical records indefinitely .
Professionals who are primary custodians of client records should refer to additional legal requirements, such as those established by state licensing boards, regarding care for client records in the event they retire and/or close their business or practice.
THE ETHICAL IMPORTANCE OF DOCUMENTATION
Documenting according to ethical standards is relevant to all clinicians. With technological advances, digital documentation has become increasingly the norm; however, electronic health records and other forms of electronic communication pose their own 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. 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. Pope (2015) makes a poignant and powerful statement about the importance of documentation, going so far as to say that clinical records have “life-changing power.” A record’s facts, inferences, conclusions, gaps, inaccuracies, wording, and tone can affect whether a person keeps custody of a child, gets a security clearance, receives life-saving help in a crisis, or secures needed accommodations at work for a disability. When a record’s security is breached, the content – diagnosis, medications, clinical history, and a patient’s most sensitive and private information – may find its way to an array of people and organizations, perhaps exposing the patient to gossip, ridicule, identity theft, exposure of private information on social media, and worse. For example, after learning that an employee hates her job and boss, a company may “reorganize” so that the employee’s position is no longer needed. If records of a clinical psychologist’s own therapy leak out, it might damage the psychologist’s alliance with his or her own therapist and could influence current and future patients’ decisions to consult another therapist. A battered woman’s husband may discover that she was seeing a therapist, despite his threat that he would kill everyone in their family if she did so. Record keeping represents practitioners’ values as well as those of the agencies in which they work. Thus, it is important for practitioners to abide by their profession’s ethical and legal guidelines for documentation as well as practice. How does the record represent agency or practitioners’ values? The values of beneficence, nonmaleficence, autonomy (closely related to self- determination), and justice, as well as fidelity, are often cited as basic principles undergirding ethical decision-making standards of care in behavioral health.
Common questions include: ● Do the records reflect those values? ● Is what is documented in the best interest of the client (beneficence)? ● Does the documentation do no harm (nonmaleficence)? ● Does it reflect fidelity (loyalty, integrity, truthfulness)? ● Do the records indicate protection of a client’s self-determination (autonomy) and fairness, nondiscriminating language, and equal service (justice)? Good record keeping entails more than the dreaded paperwork required by agency regulations, although required paperwork often serves the same purposes as good documentation in client records. Bodek (2010) offers seven purposes of documentation, all of which have ethical implications: 1. To document professional work. 2. To serve as the basis for continuity of care by the treating provider. 3. To serve as the basis for continuity of care for subsequent providers. 4. To manage the risk of malpractice complaints and assist in the defense of such complaints. 5. To comply with legal, regulatory, and agency requirements 6. To facilitate quality assurance. 7. To facilitate coordination of care among members of the treatment team. Clinical, administrative, and legal domains of providing mental health services exist. All of them are related, overlapping, and affected by ethical documentation. Administratively, records provide accountability on several levels: to the client, funding sources, the agency, regulatory bodies, and the profession. In an ideal world, records might also provide quality assurance. Usually, no one is observing services offered. Thus, records may provide an indirect window through which to observe and monitor the quality of service. Records also provide the means for securing resources; that is, documenting “billable” services works to substantiate reimbursement and can also justify the need for additional services. Good documentation provides cumulative data that can be used to demonstrate gaps in service delivery or in the continuing education needs of staff. The data can be employed to evaluate program effectiveness and demonstrate successes. Accrediting and regulatory bodies rely almost exclusively on records to provide oversight and assessment of agency efficiency and quality. This aspect of documentation lends itself to a high risk of ethical violation as staff may be instructed or encouraged to “write for the reviewer,” and the temptation to falsify or alter records is high. The unethical practice of backdating notes or embellishing data to secure funding or accreditation may be rationalized by thinking, “If we don’t get the funding, we can’t continue providing service.” Put simply, according to Mitchell (2007): Records should be understandable and accountable. Although the Health Insurance Portability and Accountability Act of 1996 (HIPAA) does not specify what is required in a medical record,
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