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. Case Study 1 In discussing copayments with a group of colleagues, one mental health clinician at an agency that offers no sliding scale or reduced fee revealed that when a copayment is very high (e.g., $50) and the client is obviously struggling financially, she often reduces the co-payment, taking less money for herself as a result. However, she enters the higher amount (which she didn’t take) in her records and keeps knowledge of the reduced fee between herself and the client. The organization is still reimbursed for the session by the insurance company for the usual amount, which does not include the copayment. This scenario presents risks on all three levels: Clinical, administrative, and legal. Clinically, the worker is trying Legal Rationale Mental health professions have not escaped the increasingly litigious reach of our society, and proper documentation can establish the competency and qualifications of the provider. Accurate record keeping is the best protection from baseless claims. Careful documentation may mean the difference between a legal judgment for or against a worker or an organization. (Moline et al., 1998). Legally, records protect the provider by demonstrating that the treatment provided was within the professional standard of care. Thorough records assist in clarifying and justifying questionable actions by the provider or organization. In fact, the NASW (2018) lists documentation clarity in the practitioner’s notes as one of the organization’s tips for avoiding malpractice. Obtaining informed consent is not a perfunctory obligation of documentation. There are challenges and risks associated with improperly obtained informed consent (Kilkku & Halkoaho, 2022). Although it is a legal and ethical requirement in healthcare, true informed consent is difficult to obtain and substantiate. The client’s level of understanding and decision-making capacity 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
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. to do something helpful for the client, but Reamer (2009) suggests that altruism is frequently at the root of the unethical situations in which practitioners find themselves. What if other clients somehow discover this practice and perceive it as preferential treatment? Will they expect the same? Will the client interpret this as having a “special” relationship with the clinician? Will the client feel indebted to the clinician for the reduced fee? Administratively, the mental health clinician’s actions could be seen as deceptive bookkeeping practices. If the worker’s supervisor learns of the practice, might they question other documentation provided by the worker? Legally, could an argument be made that insurance fraud is being perpetrated? follow-up, and next meeting. Administrative Compliance the information is used against them in a court proceeding. Even if information is properly released and disclosed, the information now made public may have residual effects for the client. Liability insurers report that the most frequent licensing board complaints stem from perceived conflicts or damages resulting from divorce. When therapists are involved in seeing couples, this risk is salient. To obviate this risk, it is recommended that practitioners “create a documented record of resistance to disclosure” (NASW, 2018, p.1). This added informed consent requires signatures from all parties permitting the practitioner to resist disclosing records in good faith. In couples therapy this statement of neutrality protects the practitioner from being drawn into “taking sides” (e.g., of having records subpoenaed to harm the other partner). In essence, the statement explains that the practitioner is an “unbiased intermediary…and shall not act as an advocate for or against any party” (NASW, 2018, p. 1). In determining what is reasonable and customary for the public to expect from a particular profession, the courts look to the “industry standard” for guidance. Most “standards of care” are outlined by a profession’s code of ethics. Several organizations’ professional codes of ethics are recognized as the “industry standard” within the helping professions. These include the codes issued by the American Psychological Association (APA), the National
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