The Legal Defense Fund of the National Association of Social Workers states: “It is important that providers have a foundational understanding that parents generally have the right to access the medical and mental health records of their minor children. This is considered a parental right and interfering with this right should only be considered after assessing the child’s emotional condition and relationship to each parent and based on sufficient knowledge of the applicable legal standards for denying parental access to records as well as the appropriate procedures to follow. State health privacy laws may also provide procedures and/or standards for providing and denying parental access.” (NASW, 2017b) Publication A unique aspect of clinical documentation concerns clinical writing and publishing case material. Bennett (2011) illuminates the ethical dilemmas that emerge when the clinician’s responsibility to respect the client’s right to privacy competes “with the societal good of educating other professionals about the process of social work practice” (p. 11). Historically, publishing case material was an accepted practice, even without permission from the client, if the material was heavily disguised. However, with the enactment of HIPAA regulations and effortless Internet searching, clients could easily find their therapists’ publications, recognize themselves in the published writing, and perceive that their rights had been violated. No matter how many safeguards are put in place, such as using disguised information or obtaining a client’s Proper supervision points to the need for recording on two levels: The provider’s need to record services and the supervisor’s need to record addressing the performance deficiency. While there are many areas of professionalism for the supervisor to address with this clinician, the supervisor can begin by explaining to the clinician that by not providing timely documentation of her work, they are failing to hold themselves accountable and are also placing the clients, the agency, funding streams, and their own reputation in jeopardy. The supervisor can further problem- solve the issue with the clinician and determine various potential causes of the late documentation. For example: ● Does the clinician lack a knowledge base of what constitutes good documentation? ● Do they struggle with time management such that the task of documenting remains undone? ● Is their work with clients crisis-oriented, or do they have so many responsibilities that documentation does not rise to the top of the priority list? ● Does the clinician lack the resources necessary to provide timely documentation? Documenting Supervision Reamer (2015) advises that supervisors, as evidence of oversight and monitoring, must document any supervision provided. The concept of respondeat superior (“the master responds”), the legal principle in which a supervisor can be held liable for actions or inactions of their supervisees, demands it. Documentation of routine supervision is one protective risk management strategy. Barnett and Molzon (2014) advise that informed consent be a foundational agreement when beginning supervision. As they describe, this agreement is no simple thing and should include: Supervision Supervising Documentation
Legally, providers ordinarily covered by HIPAA may deny parents access to children’s treatment under certain circumstances. ● Reasonable suspicion of abuse or neglect ● Danger of substantial harm as a result of records disclosure ● Separate psychotherapy (shadow) notes ● Voluntary parental agreement In such cases, documenting justification of the denial is paramount. In addition, the clinician must have another licensed healthcare professional, who is not directly involved in the denial, review the decision to deny access. Documentation of consultation with colleagues or an ethics committee regarding the denial is advised. permission, ethical dilemmas still can exist. The utilitarian approach to ethics (the greater good prevails) would opt for benefitting the professional community, which conflicts with a more teleological viewpoint that would argue that publication might compromise the individual’s well-being. The request for permission inevitably will alter the therapeutic relationship and may pose undue influence. The client may feel coerced to agree in order to receive services. Thus, informed consent is not always perceived by the client as totally voluntary. Yet the effect of clinical writing on the treatment relationship may also be positive, particularly if the client feels their experience is noteworthy and could help others. ● Expectations, responsibilities, and obligations of both supervisor and supervisee; ● Any fees and financial arrangements relevant to the supervisory relationship; ● Scheduling and emergency contact information; ● Documentation and record keeping requirements; ● The use of any audio and video recording; ● Evaluation and feedback to include the expectations and requirements for successful completion of the training experience; ● Expectations for confidentiality and any reasonably anticipated limits to confidentiality; ● Legal requirements such as mandatory reporting requirements, expectations for use of the supervisor and when the supervisee should contact him or her; and ● Information about how and when the supervisory relationship will be ended (pp. 1052–1053). Barnett and Molzon (2014) also emphasize the importance of documenting each supervision session. They list several reasons for documenting supervision, including mitigating the possibility of misunderstandings, fostering accountability for both parties, aiding one in tracking the progress of professional development and clinical services, and using it as a risk management tool to demonstrate that supervision has occurred. The American Board of Examiners in Clinical Social Work (ABECSW) has guidelines for clinical supervision that address the documenting of supervision. Both Barnett and Molzon (2014) and the ABECSW suggest a contractual agreement be signed by both supervisor and supervisee, listing the purposes, objectives, and methods of supervision. The ABECSW position statement (2004) asserts: “The supervisor understands the responsibility to create and maintain an ongoing record of the supervision.
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