● 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 repetitive paperwork required by organizational, state, and federal regulations. 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; and 7. To facilitate coordination of care among members of the treatment team. There are clinical, administrative, and legal domains of providing mental health services, all of which are related, overlapping, and affected by ethical documentation. Each of these related domains, and the rationale for their documentation, is discussed in turn. developing a blueprint for treatment and guidance in selecting best practice interventions for a particular disorder. Bodek (2010) warns that the lack of a thorough initial assessment is likely to result in inadequate or inappropriate treatment. In some instances, the client may appreciate that there is a label to validate what they are experiencing. Identifying the problem will help determine the treatment and cure. However, strengths- seeking, solution-focused, feminist, and humanistic practitioners prefer to look at what is “right” about the client’s functioning and behavior, and often view diagnoses as pathologizing what could be considered adaptive behavior (Solomon, 2021). In light of the managed care environment, a diagnosis may be considered a “necessary evil” because reimbursement for services from health insurance companies can be secured only for a “billable” diagnosis (Patel et al., 2021). Prior to authorizing treatment, some managed care organizations may also require documentation of client need based on diagnosis. Those clinicians reluctant to diagnose because they feel it is too pathologizing might try to reframe diagnosing as providing the rationale for the clinician’s and client’s choice in treatment approaches, including strengths-based, client-centered treatments. Clinicians who choose not to accept insurance reimbursement are still professionally obligated to provide adequate documentation of services provided. Clinical Guidance Clinical documentation has typically aligned with the medical model, a colloquial term for the taxonomy of causalism, in which a linear causality of pathology is sought and described. The term medical model contrasts with behavioral health concepts of holism. Although the holistic strengths-based view is compatible with the profession’s most fundamental principles of practice, it is incompatible with the traditional disease-oriented focus of the medical profession. The medical model is further reflected in the traditional problem-oriented medical record (POMR), which documents treatment according to each “problem/ diagnosis” assigned to a client. Practitioners are forced to focus on problems rather than solutions. The medical model relies almost exclusively on documentation to reflect patients’ needs, services, and progress (Leon & Pepe, 2013). Clinicians face challenges documenting in ways that represent a shift from a medical model to health-oriented and strengths-based paradigms (Braun, Dunn, & Tomcheck, 2017; Weick, 2009). Behavioral health, particularly social work, extends the medical model to add contextual information relevant to the
a unique perspective in describing the record as an “exercise of observation and interpretation of the clients’ behaviour” (p. 29). As such, it affords the practitioner power, often focusing solely on the client, not on the interaction of the client and clinician. Access to records by - clients, agencies, and courts - serves to diminish this power by providing a window into the behavior of the practitioner. The power resides in the recorded information. Kagle and Kopels (2008) suggest that clinical record keeping has primary, secondary, and sometimes tertiary functions. The primary function is to satisfy accountability, and its secondary purpose is to support practice and professional education. Tertiary functions of record keeping involve research and data analyses. nonmaleficence, autonomy, justice, and fidelity are often cited as basic principles undergirding an ethical decision-making standard 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)? How does the record represent the organization’s and practitioners’ values? The values of beneficence, ● Does the documentation do no harm? (nonmaleficence) ● Does it reflect fidelity (loyalty, integrity, truthfulness)? Clinical Rationale Record keeping is both a process and a product. Although there is overlap, the process of recording generally serves as a guide for the clinician and client; the clinical elements in a client’s record can provide guidance for the practitioner about the direction of the client’s ongoing or future therapeutic work, and the product of documentation serves as proof of this clinical interaction for administrative purposes. Professional record keeping allows for good care; assists collaborating professionals in delivery of care; ensures continuity of professional service; ensures appropriate supervision or training; provides requisite documents for reimbursement; and documents decision making, especially in high-risk situations. Ideally, the process of documenting serves as a quality assurance tool by making clinicians reflect upon and evaluate their clients and their work. Quality record keeping of clinical services is valuable in facilitating quality treatment. “Through the recording process, which involves selecting, reviewing, analyzing and organizing information, the practitioner comes to a better understanding of the client-need-situation” (Kagle & Kopels, 2008, p. 10). In addition to being the compilation of case history and activity, records provide a planning tool for future interventions with a client. Most practitioners have large caseloads and need to rely on records for keeping track of case information and details. Notes allow the clinician to discern patterns of behavior or interpersonal styles that can direct treatment. Clinical documentation can also be used to monitor and track treatment progress. Extreme views on the importance of documentation suggest that the quality of the record will reflect the quality of the care. Additionally, documenting is an important tool in clinical skill development for the training and education of behavioral health providers. Professional social work, for example, has historically relied on the case method and process recording as a means to train students in “communication and relationships, and processes of assessment, intervention, and evaluation” (Kagle & Kopels, 2008, p. 17). Diagnostic Impressions Records typically include the client’s relevant history and the clinician’s diagnostic impressions - which are usually revealed within the first few sessions. Some practitioners prefer not to attach labels to people, particularly their clients. Although this approach may seem altruistic in some ways, it can be misguided. Providing a presumptive diagnosis may assist the practitioner in
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Book Code: SWTX1524
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