Content of Documentation Good documentation requires organization, decision making, critical conceptualization, and effective writing. Good clinical documentation has specific elements of organization and writing (Bodek, 2010). According to Kagle and Kopels (2008), good clinical records will demonstrate these 15 principles: 1. Balance - of the valued but competing goals of accountability, practice improvements, efficiency, and client privacy 2. Focus on the mission - with content relevant to the agency mission or program objectives 3. Risk management - achieved by good compliance with agency policy, legal standards, practice guidelines, and professional ethics 4. Accountability - with a focus on service delivery, impact, and outcome 5. Abridgement - exclusion of information that is not pertinent to purpose, goals, or outcome of service 6. Objectivity - presentation of information that is fair and impartial and that includes observation, sources of information, criteria used in assessment, and appraisal 7. Client involvement - documentation of the client’s role in all aspects of the process 8. Sources - provision of sources for all information 9. Cultural context - inclusion of cultural factors influencing the client’s situation or service 10. Access - information written with the assumption that anyone may have access to it 11. Usability - organization of records, usually chronologically, in a reader-friendly way 12. Currency - records kept current with periodic reviews and updates 13. Rationale - provided for all service decisions 14. Urgent situations - full documentation of emergencies or crises 15. Exclusions - of irrelevant, extraneous, opinionated, or speculative information The minimally required content for good clinical documentation in a case record would include agency- specific templates and formats, such as documentation of informed consent and confidentiality limits, case notes, assessments, and diagnostic codes. Sometimes organizations provide templates for certain parts of a case record (e.g., consents, releases of information, assessments) to increase the uniformity of the record; however, the quality of case notes in particular is largely dependent upon the individual clinician’s skill in documentation apart from their interviewing skills and ability to elicit the information that is necessary and relevant to the therapy. Discerning what is sufficient, necessary, and relevant to document is as much a practitioner skill as learning therapeutic techniques. The clinician’s interpretation of information to document, and the method by which to document it, determines the quality of the documentation. Practitioners should document with the expectation that a much wider audience than expected may read what is written. The content of excellent clinical documentation provides insight into client needs, justifies and chronicles the course of intervention, and demonstrates progress and outcomes. Mitchell (2007) takes the viewpoint of charting for the reader. He proposes basic principles to create a useful record for colleagues and clients. ● Language should be clear and specific, avoiding irrelevant statements or excess verbiage. ● Whenever possible, the client’s own words should be used. Write what is heard.
Association of Social Workers (NASW), the American Counseling Association (ACA), the American Psychiatric Association (APsyA), the American Association for Marriage and Family Therapy (AAMFT), the Association for Specialists in Group Work (ASGW), and the National Board for Certified Counselors (NBCC). Some clinicians keep two sets of notes on clients: one for the official record and a second set with personal comments, interpretations, and cues for clinical intervention. This second set of notes is commonly referred to as “personal notes” or “shadow records” (Sidell, 2015) for legal purposes, but the distinction between the official record and personal notes varies by state. Most states make no distinction, and thus both sets of records are subject to subpoena. States that recognize a distinction do not require that personal notes be considered under a subpoena. Practitioners are advised to check their state’s law on what is considered part of the “mental health record.” Sidell (2015) advises that the safest risk management approach is to destroy informal notes after using them as aids for recording the official notes in the case file. Subpoenas are often anxiety producing for health practitioners but erring on the side of documenting too little or too much can exacerbate the situation. It is advisable to keep all documentation, including electronic communications, for protection in a lawsuit. It is also important not to make any changes to the record after receipt of a subpoena (Wiger, 2022). Certain risk management strategies will help reassure the practitioner who fears revealing records in legal proceedings. Managing risk in documentation involves these critical four areas. 1. Content 2. Language 3. Credibility 4. Access Sidell (2015) gives specific examples of “people-first language” to avoid any hint of defamation or discrimination. For instance, most contemporary practitioners are aware that the emphasis should be on “having” a condition, rather than “being” a condition and would write, “He has a mental health condition” instead of “He is mentally ill” or “She has a diagnosis of autism” instead of “She is autistic.” However, more vague references might escape even the most conscientious worker. Finally, because documenting psychotherapy has evolved from the medical model, it is the accepted standard in most clinical work to keep accurate, timely, and sufficient records. Both what is written and what is not written can be potentially problematic. Malpractice claims can be brought based on acts of commission (actions taken) and omission (actions not taken). Documentation can verify what has or has not taken place in a therapeutic encounter, and the risk of legal repercussions extends also to what is or is not written in the documentation itself (Wiger, 2022). In resolving legal claims, courts may consider issues of malfeasance and nonfeasance. Malfeasance is when an action is performed in a flawed way, such as conducting an incomplete suicide assessment. Nonfeasance is when a required action is not performed at all, such as not performing a suicide assessment when indicated. Only solid documentation would elucidate whether a practitioner’s actions constituted malfeasance or nonfeasance and exonerate a practitioner or protect a client’s best interest. Simply put, good records benefit the client, the clinician, the agency, and the profession. They “serve and protect all parties.”
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Book Code: PYTX1325
EliteLearning.com/Psychology
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