Case Record Research: Integrated Care in New Zealand A recent study in New Zealand explored case records and the related dynamics involving accessing and sharing documentation within integrated care settings, revealing several issues worthy of study. The research outlines several principles involved in effective documentation and an ethical analysis of record-keeping practices. According to the authors (Cairns et al., 2018), their research uncovered the overarching ethical concern of providers that records can influence professional opinions about the patient, for better and for worse. Given this ethical concern, the authors identified three core principles that providers followed in their recording decisions: Neutrality, accuracy, and necessity.
Necessity in record keeping is about making recoding judgements, and an incomplete record can impair the care that patients receive (Tabesh et al., 2022). These professional decisions help provide safe and effective care for patients as they interact within the system of care and with the various members of the integrated treatment team. 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). 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).
Neutrality as a guiding ethic in recording decisions is usually well understood among behavioral professionals who are experienced in clinical practice (Corey et al., 2020). However, for younger professionals or those who are new to integrated care settings, their perceived view of this ethic might benefit from additional information. For example, a provider “who has reached an unfavourable assessment of a client is less likely to be motivated and concerned in the appropriate way and is thus less deserving of the client’s trust. Pejorative judgements, if discovered, are likely to be resented by clients and to damage the trust required to sustain therapeutic success” (Cairns et al., 2018, p. 363). Moreover, in integrated care settings the case record is shared, creating greater necessity for neutrality to ensure other professionals aren’t unnecessarily biased against the patient. Accuracy is perhaps the best understood principle when making recording decisions. Providers must adhere to factual representations of objective factors discussed within sessions, especially those factors which are crucial to the patient’s health record, for example, suicidal ideation, intentions to harm others, or disclosed abuse of minors. More complicated in recording methods is the inclusion of accurate subjective factors, data which are less quantifiable, yet create definite impressions upon the provider. As discussed by Cairns and colleagues, “[T]he greater challenge in the social work context is recording the contestable, less demonstrable information, observations and assessments that support the team’s understanding of the client’s situation. The nature of the role means that social workers are especially likely to encounter the challenges that accuracy poses to the recording of opinions, impressions and unverifiable statements” (Cairns et al., 2018, p. 362). For example, clinicians might have intuitive reactions during a session with a patient that are counter to the objective report made by the patient. This can often be the case with undisclosed suicidal ideation on the part of the patient, who can be embarrassed about disclosing suicidal thoughts or plans. Clinical intuition is subjective and needs to be understood as a clinical hunch that needs to be investigated, often by other providers serving the same patient within an integrated care setting. This approach widens the clinical lens placed upon the patient and can lead to a sound clinical consensus of risk factors or disorders that may be affecting the patient.
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
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