THE RATIONALE FOR DOCUMENTATION
Frederic G. Reamer (2009), one of the architects of the current NASW code of ethics, describes documentation as one of the most important skills in behavioral health practice. The clinical need for thorough, accurate, and timely documentation to ensure quality service delivery cannot be overemphasized. In addition, given the growing demands of managed care and utilization review, documentation is increasingly more important in healthcare settings as accountability, clinical accuracy, and treatment outcomes determine funding and the level of authorized services. The NASW Code of Ethics (2017a) reflects the impact of swift technological change on practice, including treatment options as well as storing, retrieving, and documenting client data, particularly in electronic health records. The vignettes included in this course are designed to illustrate many of the reasons for good clinical documentation, as well as some of the ethical risks, fears, mistakes, and myths of documenting in the helping professions. What drives documentation? Who is it for? Whose interest does it serve? Record keeping is a safeguard for both practitioners and clients. Good clinical documentation primarily meets the needs of the client, practitioner, and agency; however, it is also intended to meet the needs of the supervisor, professional boards, regulatory organizations, and accrediting bodies. O’Rourke (2010) provides 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 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
education. Tertiary functions of record keeping involve research and data analyses. How does the record represent the organization’s and practitioners’ values? The values of beneficence, 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)? ● 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 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. 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 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.
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