HIPAA compliance folder (Bodek, 2010). This regulation sets up a baffling conundrum in that healthcare facilities usually maintain a single consolidated medical record for each client that includes all consultations, including behavioral health interventions. As a result, the therapist may maintain their own clinical or shadow notes, which may be considered “personal” but are nevertheless subject to the same legal scrutiny as the official record. Some clinicians argue from a minimalist perspective that the less that is written, the less there is that can hurt the clinician or the client. Under the guise of protecting client confidentiality, these clinicians may err on the side of maintaining too little documentation. Some practitioners have argued against keeping detailed records, based on the contention that confidentiality can be best protected as a way to avoid litigation with no documentation at all, particularly if the client requests minimal documentation. Although the professional debate is not over, this argument may be shortsighted in the present digital and litigious era; in fact, lack of documentation could potentially make a practitioner more liable and simultaneously do a disservice to the client (Wiger, 2022). Other clinicians may provide too much documentation, thinking that more is better. This practice may also be problematic in that superfluous information may confound what is crucial to the client’s treatment. It is difficult to Informed Consent Informed consent has been called the “quintessential document” in the provision of mental health services (Bradshaw et al., 2014). In addition to being one of the first documents to comprise a record, it is one of the best risk- management tools. Informed consent in today’s healthcare milieu demands details not previously considered, including Relevant History Mental health treatment emphasizes treating people in context. This is known as the person-in-environment approach and relies on gathering and documenting relevant history from the patient and collateral sources. Psychosocial assessments that include a client’s history, along with tools such as genograms, document the context for establishing a case formulation of a client’s current functioning. The combination of medical and psychosocial information provides an important history that contributes to the clinician’s understanding of the patient’s current level of functioning. Information relevant to the client’s life history includes childhood development, school, family and other significant relationships, employment, socioeconomic status, sexuality, and substance abuse. Exploration of the presenting problem requires an examination of the history Progress Notes Progress notes are written documentation detailing every session. Despite the fact that progress notes are susceptible to error, good progress notes protect practitioners against future litigation regarding misdiagnosis or treatment. What constitutes a good progress note? A good progress note not only proves that an encounter took place but also details the type and effect of treatment so that any reader can ascertain a client’s issues, diagnosis, and progress in therapy. Progress notes should include information about each session’s content or topics, their relevance to treatment plan objectives and goals, and the use of interventions and their outcomes. Progress notes should reflect the current status (based on the therapist’s clinical observation during the session) of a client’s diagnosis, the medical necessity of services, and progress or setbacks in relation to treatment objectives and goals (Wiger, 2022).
imagine that behavioral health practitioners can remember every detail about a client without referring to their records. For example, imagine the therapeutic rupture that would result if a therapist in session confused one client’s history with that of another client. The clinician’s review of their thoughtful records prevents such an unnecessary error. Imagine the reaction of a patient who visited their physician and found that nothing was charted about their medical history, current complaints, or medication prescribed. Likewise, in behavioral health, good record keeping can help establish rapport as a client sees that what they have to say is worth noting, literally and figuratively. Record-keeping content and especially format may vary considerably across settings. Agencies dictate the specific format. The APA revised guidelines for record keeping suggest that for practitioners in agencies or private practice, “records document the nature, delivery, progress and results of services” (Drogin et al., 2010, p. 237). Therefore, three kinds of content should exist across settings: (1) General file information such as demographics and reasons and goals for service; (2) substantive contacts, including date and duration with client and collaterals, the context and approach to services, tests, and progress; and (3) supplemental information such as assessment results, measurements or tests, and client journals or drawings. potential benefits and risks of engaging in treatment, the nuances of technology use, limitations on confidentiality, and mandated reporting. “Failure to obtain or document consent can result in serious consequences, including problems in the therapeutic relationship and legal action” (Bradshaw et al., 2014, p. 3). of the problem, including the onset, context, and events triggering current help-seeking. A well-documented assessment, however, presumes that the documenter has interviewing skills that will elicit the important information needed for good documentation (Leon & Pepe, 2013). Yet it also depends on the practitioner knowing what and how to document. The biopsychosocial assessment is the foundation of a clinical record. It encompasses multiple areas related to the client’s history and functioning. Essentially, the assessment unpacks the presenting problem; describes it in context; documents relevant developmental, family, medical, interpersonal, educational, employment, and social history; and identifies client strengths and limitations, including risk and protective factors (Wiger, 2022). Kagle and Kopels (2008) recommend that progress notes should include the following information: ● Any new information about the client’s needs ● The provider’s assessment of the client’s status with regard to needs ● The client’s actions or activities related to the service plan ● Services provided by the provider ● Evaluation of progress ● Any changes needed to meet the goals of the service plan Although these guidelines might seem overwhelming to the hurried practitioner who has too little time between sessions to record their notes, they do provide a goal for documenting.
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Book Code: PYTX1325
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