____________________________________________ Professional Ethics and Law in California, 2nd Edition
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, inaccura- cies, 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 accommoda- tions 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 infor- mation – 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. Com- mon 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
1. To document professional work. 2. To serve as the basis for continuity of care by the vtreating provider. 3. To serve as the basis for continuity of care for sub- sequent 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 require- ments. 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, overlap- ping, 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 reim- bursement 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 con- tinuing 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 encour- aged 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.” Although the Health Insurance Portability and Account- ability Act of 1996 (HIPAA) does not specify what is required in a medical record, according to Groshong and Phillips (2015), the following must be included to meet behavioral health guidelines: • Billing information and payment records • Formal evaluations • Collateral contacts, including release of information (ROI) for all • Records from other providers with ROI • Counseling session dates, with start and stop times • Modalities and frequency of treatment • Medications
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 documenta- tion in client records. Bodek (2010) offers seven purposes of documentation, all of which have ethical implications:
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