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 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
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 patient’s needs, services, and progress. Of course, diagnostic impressions are not just clinical diagnoses, and thorough assessment of the client’s situation is not captured with only a diagnostic label. “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 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.
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Book Code: PYTX1325
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