patient’s needs, services, and progress. Of course, diagnostic impressions are not just clinical diagnoses, and thorough Administrative Rationale One of the primary functions of documentation is to create and provide a central record for all collaborating providers. This record is used for clinical purposes and, increasingly, for administrative purposes (Mulholland & Healy, 2019). Third-party requirements such as the funding stipulations of managed care or regulatory bodies for accreditation are often the driving force behind documentation. Additionally, funding sources are demanding more evidence-based practice (EBP) and outcome-oriented interventions. Documentation practices are following the emergence of EBP, thus helping treatment approaches and outcomes appear in a clear documented form. Increasingly, funding streams require proof of EBP for approval and reimbursement of services. Funding sources look for accountability of monies allocated through evidence of service effectiveness. Three areas in which EBP is supported by documentation are client needs and presenting factors, services (treatment activities), and client outcomes, thus creating a precise record of patient-related events. A major administrative reason for documentation is to satisfy managed care utilization review requirements. Records are reviewed prospectively for authorization of services, concurrently for monitoring services, and retrospectively for billing purposes or report-writing. Interestingly, ethical concerns have increased in the managed care milieu as the restrictions imposed by “managing” care are perceived as “limiting” care and the temptation to embellish records to justify even minimal care presents itself as an option. Critical incidents often showcase the advocacy skills that are needed to confront the funding restrictions which govern what is considered necessary and what is authorized (Kane et al., 2002). When securing continued services, the clinician must advocate for the client, rather than inflating the records or the problems documented within them. Program Accountability Administratively, records can provide accountability on several levels: To the client, funding sources, the organization, regulatory bodies, and the profession (Ramanuj et al., 2019). In an ideal world, records might also provide quality assurance. Treatment is normally not observed by a third-party evaluator; thus, records may provide an indirect window through which to observe and monitor the quality of service. Lastly, records provide the means for securing resources; that is, documenting “billable” services serves 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 used 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.” Records also meet the needs of the management team, as they are often used to assist in workload planning and distribution, and for internal reviews to evaluate compliance with both internal and external stipulations. Supervision Good record keeping not only protects the client and the process but also facilitates the practitioner’s professional development. A supervisor’s review of records is a valuable tool for evaluating and remediating the knowledge and skills of the practitioner. In a strong supervisory relationship, the supervisor
assessment of the client’s situation is not captured with only a diagnostic label.
will use the supervisee’s documentation to highlight noteworthy aspects of a particular case or assess the practitioner’s caseload (Kagle & Kopel, 2008). In contrast to the more common use of records to demonstrate inadequacies, this approach uses the record constructively to encourage reflection and ultimately improve practice. Sidell (2015) emphasizes that documentation should remain a topic in supervision. It should be valued as a skill, equal to any clinical skill in the worker’s repertoire. Furthermore, because of liability concerns, supervisors should document supervisory encounters with supervisees. However, documenting the supervision itself is a commonly neglected task. Although supervisors may demand thorough documentation of clinical encounters from their supervisees, supervisors often give far less attention to documenting their own work with staff. In the spirit of parallel process, supervision sessions should be documented for the same reasons that client interaction is documented. Supervisors should document time, date, and content of supervisory sessions. Mental health administrators should document any discussions pertaining to ethical decision making. As mentioned, all supervision encounters should be documented (Association of Social Work Boards, 2009; Barnett & Molzon, 2014). Recording supervision protects supervisor, supervisee, the organization, and – indirectly - clients. Although supervisors may stress the importance of documenting clinical services by their supervisees, equal emphasis on documenting supervision is not common practice. According to Barnet and Molzon, documentation of supervision can “(a) help reduce the chance of misunderstandings occurring, (b) help increase accountability on the part of the supervisee, (c) be an excellent aide for both parties when reviewing to track progress both of the supervisee’s clients and the supervisee’s professional development, and (d) serve an important risk management role in providing a tangible record of what has transpired in supervision and the supervisor’s efforts so provide high-quality clinical supervision” (2014, p. 1057). Themes noted, cases discussed, educational needs, and supervisor’s impressions and recommendations are all appropriate content for a supervision note. Documenting supervision for licensure purposes is particularly important for potential audits. Sidell (2015, p. 191) proposes a guide to structure supervisory notes using the acronym SUPERS: S - supervisee-initiated items U - useful feedback or suggestions from the supervisor PE - performance expectations that have been discussed R - recommendations for future goals S - strengths of the supervisee Sidell also provides a sample format for documenting group supervision that records date, participants, topics explored, Of the seven purposes of documentation identified by Bodek (2010), the last four could be viewed as administrative in nature. Again, these purposes are: ● To manage against the risk of malpractice complaints and to assist in the defense of such complaints; ● To comply with legal, regulatory, and organizational requirements; ● To facilitate quality assurance; and ● To facilitate coordination of care among members of the treatment team. follow-up, and next meeting. Administrative Compliance
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