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, inaccuracies, 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 accommodations 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 information – 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. Common 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 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 documentation in client records. Bodek (2010) offers seven purposes of documentation, all of which have ethical implications: 1. To document professional work. 2. To serve as the basis for continuity of care by the treating provider. 3. To serve as the basis for continuity of care for subsequent 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 requirements 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, overlapping, 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 reimbursement 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 continuing 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 encouraged 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.” Put simply, according to Mitchell (2007): Records should be understandable and accountable. Although the Health Insurance Portability and Accountability 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. ● Diagnoses. ● Functional status (activities of daily living [ADL], ability to work, interpersonal capacity). ● Medical/physical problems. ● Community contacts, including phone calls, emails, or texts. ● Treatment plan and goals. ● Symptoms and prognosis. ● Progress in each session. ● Disclosure forms and informed consents signed by the licensed professional and client. ● Presenting problem(s) or purpose of visit. ● Referrals to and results of formal consultations. ● Progress notes sufficient to support responsible clinical practice for the type of orientation/therapy used. All digital medical records should be backed up regularly and kept in encrypted format, with frequent changes in passwords. Although there can be both a medical record and psychotherapy notes, information cannot be put into psychotherapy notes to avoid putting it into the medical record (Groshong & Phillips, 2015). Obtaining informed consent is not a perfunctory and merely obligatory part of documentation. There are actually risks associated with it. Although it is a legal and ethical requirement in health care, true informed consent is difficult to obtain and substantiate. The level of understanding and decision-making capacity of the client can vary across time and situations. Although a client may give consent for disclosure of information, for example, that disclosure may inadvertently backfire, possibly causing the client harm. Clients may be harmed by released health information that is improperly disclosed by the third-party recipient or when the information is used against them in court proceedings. Even when properly released and disclosed, the information now made public may have residual effects for the client. In our digital world, informed consent should now include explanation for clients regarding the use of technology “to gather, manage and store protected health and other sensitive information” (Reamer, 2018a). The Health Insurance Portability and Accountability Act regulations have affected how client records are organized and what may be included. Documentation is often considered synonymous with record keeping; however, documentation encompasses many aspects, formats, and types of record
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