CONCLUSION
The importance of clinical documentation rests firmly on the concept of accountability, namely, clinical, administrative, legal, and ethical responsibilities. Understanding what and how to document is the ethical responsibility of the practitioner. The complexities and nuances of clinical record keeping demand an informed approach, and certainly continuing education and training are essential. Documenting in the digital world requires particular attention. The rapid expansion of telehealth and online modalities has made this clear. Clinical records serve multiple purposes in the current healthcare arena. In particular, in the increasingly complex and litigious realm of mental health practice, the balancing act required for practitioners to document sufficient, necessary, and helpful information, with risk-management principles in mind, illustrates that clinical record keeping should not be taken lightly. The challenge for clinicians is to adhere to the profession’s values and ethics, while documenting client information and the therapeutic encounter. Generally, documenting more process and less content is a good risk-management strategy. Records should Resources ● Barnett, J. E., & Johnson, W. B. (2008). Ethics desk reference for psychologists. American Psychological Association. ● Written for psychologists and useful for cognate professionals, this reference supports mental health professionals in navigating ethical responsibilities. ● Barsky, A. (2009). Ethics and values in social work: An integrated approach. Oxford University Press. ● For practitioners interested in learning more about social work ethics, this resource provides practice vignettes, discussion questions, and role-playing exercises. ● Corey, G., Corey, M. S., & Callanan, P. (2014). Issues and ethics in the helping professions (9th ed.). Thomson. ● Written by marriage and family therapists, this book emphasizes a practitioner’s critical thinking as an approach to managing ethical concerns and includes opportunities for self-directed learning. ● Corey, G., Haynes, R. H., Moulton, P., & Muratori, M. (2020). Clinical supervision in the helping professions: A practical guide. John Wiley & Sons. ● Guide for practicing supervisors seeking the knowledge and skills necessary to effectively supervise others offering a unique glimpse at key issues in the theory and practice of supervision. ● Kantrowitz, J. L. (2006). Writing about patients: Responsibilities, risks, and ramifications. Other Press. ● Interviews with psychoanalysts comprise an exposition on the ethical conundrum of publishing cases, balancing the need to advance professional literature with the necessity of protecting client confidentiality. ● Martha St. Enterprises, Inc. (2009). You can learn to write effective, clear and professional case notes. ● http://www.become-an-effective-psychotherapist.com/case- notes.html ● This website describes charting as the practice of keeping objective documentation on clinical interventions. Numerous and specific examples of different types of case notes are provided. Appendix: Summaries of Ethics Codes Relevant information regarding record keeping American Association for Marriage and Family Therapy Ethics Code (2015) http://www.aamft.org/imis15/content/legal_ethics/code_of_ ethics.aspx Standard II: Confidentiality 2.5 MFTs [marriage and family therapists] comply with applicable laws and professional standards with respect to storing, safeguarding, and disposing of records such that clients’ confidentiality is protected.
reflect the clinician’s competence, intentionality, and decision- making process in weighing options; the rationale for treatment; and awareness of relevant clinical, ethical, and legal information. Given the pivotal role of record keeping in behavioral health practice, and the fact that it often takes up more than half of a practitioner’s time, creating an ethical and practical document is not adequately addressed in professional training (O’Rourke, 2010). The complex nature of healthcare documentation in the twenty-first century requires ongoing education. In a review of the APA’s revised record-keeping guidelines, Drogin and colleagues (2010) conclude that “record keeping issues are ever-present and are inextricably bound up in Ethics Code requirements, ignorance of which could lead to very serious consequences for everyone involved. The topics [of record keeping] are of pressing importance, and their complexities merit or close attention” (p. 242). This course provides the information and knowledge needed to better understand the complexities of documentation. ● National Association of Social Workers (NASW). (2017). NASW, ASWB, CSWE, & CSWA Standards for Technology in Social Work Practice. NASW Press. https://www.naswpress. org/product/53594/nasw-aswb-cswe-amp-cswa-standards- for-technology-in-social-work-practice ● This publication provides a uniform set of technology standards to use as a guide in practice. ● National Association of Social Workers (NASW). Legal issue of the month. ● http://www.socialworkers.org/ldf/legal_issue/default.asp ● The “Legal Issue of the Month” addresses a particular legal topic relevant to social work practice that focuses on a recent court decision or emerging legal issue. The site hosts 100 free legal articles for NASW members and addresses commonly asked questions as well as complex current or ethically challenging issues. ● NASW. (2007). Social workers and e-therapy. http://www. socialworkers.org/ldf/legal_issue/2007/200704.asp ● This article discusses various electronic modalities of treatment, social work practice standards, and research. It also touches on the relationship that other health professions have with electronic media. ● National Board for Certified Counselors (NBCC). (2016). National Board for Certified ● Counselors policy regarding the provision of distance professional services. ● http://www.nbcc.org/Assets/Ethics/ NBCCPolicyRegardingPracticeofDistanceCounselingBoard. pdf ● This policy provides information for counselors regarding the use of technology in the delivery of counseling services. ● Reamer, F. G. (2012). Boundary issues and dual relationships in the human services. Columbia University Press. ● This book offers a thorough analysis of common boundary issues in the helping professions. Specific examples with suggested guidance on risk management are highlighted in each chapter. 2.6 MFTs arrange for the confidentiality, storage, transfer, safeguard, or disposal of client records in the event of the therapist’s move from the area, practice closure, or death in conformance with applicable laws. Standard III: Professional Competence and Integrity 3.5 MFTs maintain clinical and financial records in accordance with applicable law.
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Book Code: SWTX1524
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