Supervision/consultation is important for documenting ethical decision making. It is important to consult with colleagues, including supervisors, in formulating an ethical decision, and Decision Making in Documentation Case Study 7 During a session a client threatened to punch her former boyfriend’s present girlfriend in the face. The worker speculated whether this admission met the criteria for a duty to warn. She pondered whether to document the threat, thinking that if she didn’t document it there would be no chance of either her client or herself being hurt legally. After the client willingly provided her boyfriend’s number, she did call him and his girlfriend and provided the warning to both. She considers her ethical obligation met but still wonders if it is necessary to document the interchange. These questions guide the necessity to document: ● For whom is the note written? (Is the information for the agency, the practitioner, collateral or subsequent practitioners, or the client?) ● Is it necessary? (Does the information further the goals of treatment or link other aspects of treatment?) ● Is it useful? (Does the information relate to the treatment goals, or is it extraneous?) ● Is it sufficient? ● Is it true? ● Who might read it? ● Who should/could read it? ● Are there jurisdictional statutes that require it?
it is equally important to consult about what to document in the process. The same principles used to document services to clients apply equally to documenting supervision.
Reamer (2012) suggests applying choice architecture, a decision- making framework used in business, to ethical decision making, and it can be further applied to decisions about documentation. Choice architecture, a concept that originated in the economics and business fields, has recently appeared in the behavioral sciences literature. Choices are constructed in much the same way that steps are placed in strategic areas of building construction, and the placement of the steps themselves then influences the choices people make. The concept of choice architecture can be used to assist in determining what to document in a clinical record. The concept advises that a clinician should expect error and manage the risk. The architecture of choice in ethical decision making applied to clinical record keeping suggests that the clinician should ask: ● What would happen if I don’t document? (Do nothing.) ● Should I consult? (Who should/could be involved in this decision?) ● What if . . .? (Always anticipate errors and the need for risk management.) In building a case for documenting, the default decision is to do nothing. This decision certainly has its risks. Ideally the next step is to get feedback. The ultimate step is to expect error and manage the risk. Reamer (2009) provides an ethics audit tool to manage risk in an agency in multiple areas. Documentation is one area the ethics audit addresses in which practitioners’ documentation styles and procedures should be assessed. The audit notes whether documentation routinely includes the following components. ● Social history, assessment, and treatment plan ● Informed consent ● Collateral contacts ● Multidisciplinary consultation ● Justification for choice of intervention ● Critical incidents ● Recommendations to the client ● All contacts with clients, including type, dates, and times
And perhaps the most important question: ● What might happen if I don’t write it?
The concept of negative responsibility is the ethical notion that a person is equally responsible for inaction as for action. Negative responsibility plays into deciding what to document and what not to document. The skill of conceptualizing important themes without potentially damaging detail develops over time with experience. Mitchell (2007) expands on this concept by assuming the voice of a coworker when documenting. If a coworker was to read the note, would they find it sufficiently clear to ensure continuity of care? A client is not served well when a coworker is challenged to interpret incomplete records. Suppose a coworker is charged with covering for a sick colleague. They read in the notes: “Client often acts inappropriately in session.” The coworker is left to their imagination to wonder if the client laughs inappropriately, makes sexual overtures, or lunges across the room unexpectedly. Mitchell (2007) labels this charting as using “conclusionary terms” without substantiation and goes further to imagine a client reading such powerful, potentially damaging documentation.
● Failed or missed appointments ● Previous relevant medical history
● Billing information ● Termination notes
In addition, documentation should be evaluated for anything that might imply defamation of character, including libel. “Social workers can be liable for defamation if they say or write something that is untrue, they knew or should have known to be untrue, and caused some injury to the plaintiff” (Reamer, 2015, p. 141). especially difficult to diagnose given that neurodevelopmental periods are not specifically defined, development among children varies widely, symptom patterns are difficult to detect within a short history, and children are reactive to family and environmental stress” (p. 196). Specifically, this problem is evident when clinicians, using categorical diagnostic criteria, try to ascertain if children’s behavior and symptomatic presentation are within normal ranges, subacute, or abnormal and severe. A 2002 survey of 495 child and adolescent psychiatrists, 497 developmental and behavioral pediatricians, and 500 pediatricians sought to understand the coding decisions made by this group when assessing, diagnosing, and treating children and adolescents. Nearly 70% of the respondents said they engage in routine imprecise coding, namely up-coding or down- coding. The practice of up-coding is a diagnostic method of exaggerating the severity of the presenting symptoms, whereas
Documentation Decisions: The Ethics of Diagnostic Codes for Children Professional division exists within behavioral health when considering the utility of recording diagnostic codes for child patients. Researchers are investigating anew the clinical utility of traditional diagnostic criteria, namely the criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). These authors are investigating the usefulness of alternative diagnostic criteria that identify mental health and mental illness as being found within a continuum of functioning and circumstances, not within the circumscribed categories that are often associated with the DSM and the ICD (Cartwright, 2018). Cartwright highlights the concern, stating that “clinicians have recognized that the current categorical approach implies a discontinuous nature of mental health and does not allow recognition of the full spectrum and complexity of psychiatric disorders” (Cartwright, 2018, p. 196).
According to Cartwright (2018) , ethical decisions abound when considering diagnostic decisions because “children are
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