Records must be kept in accordance with state and federal laws as well as agency policy. Accurate and thorough record-keeping is an important aspect of job management and provides protection in case of a legal challenge to the quality of the services provided” (p. 26). The NASW (2017b) standards state: “Documentation is an important legal tool that verifies the provision of services. Supervisors should assist supervisees in learning how to properly document client services performed, regularly review their documentation, and hold them to high standards. Each supervisory session should be documented separately by the supervisor and the supervisee. Decision Making in Documentation Case Study 7 During a session a client threatened to punch her former boyfriend’s present girlfriend in the face. The worker speculated whether this admission met the criteria for a duty to warn. She pondered whether to document the threat, thinking that if she didn’t document it there would be no chance of either her client or herself being hurt legally. After the client willingly provided her boyfriend’s number, she did call him and his girlfriend and provided the warning to both. She considers her ethical obligation met but still wonders if it is necessary to document the interchange. These questions guide the necessity to document: ● For whom is the note written? (Is the information for the agency, the practitioner, collateral or subsequent practitioners, or the client?) ● Is it necessary? (Does the information further the goals of treatment or link other aspects of treatment?) ● Is it useful? (Does the information relate to the treatment goals, or is it extraneous?) ● Is it sufficient? ● Is it true? ● Who might read it? ● Who should/could read it? ● Are there jurisdictional statutes that require it?
Documentation for supervised sessions should be provided to the supervisee within a reasonable time after each session. Social work regulatory boards may request some form of supervision documentation when supervisees apply for licensure. Records should be safeguarded and kept confidential.” Supervision/consultation is important for documenting ethical decision making. It is important to consult with colleagues, including supervisors, in formulating an ethical decision, and it is equally important to consult about what to document in the process. The same principles used to document services to clients apply equally to documenting supervision. decision making, and it can be further applied to decisions about documentation. Choice architecture, a concept that originated in the economics and business fields, has recently appeared in the behavioral sciences literature. Choices are constructed in much the same way that steps are placed in strategic areas of building construction, and the placement of the steps themselves then influences the choices people make. The concept of choice architecture can be used to assist in determining what to document in a clinical record. The concept advises that a clinician should expect error and manage the risk. The architecture of choice in ethical decision making applied to clinical record keeping suggests that the clinician should ask: ● What would happen if I don’t document? (Do nothing.) ● Should I consult? (Who should/could be involved in this decision?) ● What if . . .? (Always anticipate errors and the need for risk management.) In building a case for documenting, the default decision is to do nothing. This decision certainly has its risks. Ideally the next step is to get feedback. The ultimate step is to expect error and manage the risk. Reamer (2009) provides an ethics audit tool to manage risk in an agency in multiple areas. Documentation is one area the ethics audit addresses in which practitioners’ documentation styles and procedures should be assessed. The audit notes whether documentation routinely includes the following components. ● Social history, assessment, and treatment plan ● Informed consent ● Collateral contacts ● Multidisciplinary consultation ● Justification for choice of intervention ● Critical incidents ● Recommendations to the client ● All contacts with clients, including type, dates, and times ● Billing information ● Termination notes In addition, documentation should be evaluated for anything that might imply defamation of character, including libel. “Social workers can be liable for defamation if they say or write something that is untrue, they knew or should have known to be untrue, and caused some injury to the plaintiff” (Reamer, 2015, p. 141). ● Failed or missed appointments ● Previous relevant medical history
And perhaps the most important question: ● What might happen if I don’t write it?
The concept of negative responsibility is the ethical notion that a person is equally responsible for inaction as for action. Negative responsibility plays into deciding what to document and what not to document. The skill of conceptualizing important themes without potentially damaging detail develops over time with experience. Mitchell (2007) expands on this concept by assuming the voice of a coworker when documenting. If a coworker was to read the note, would they find it sufficiently clear to ensure continuity of care? A client is not served well when a coworker is challenged to interpret incomplete records. Suppose a coworker is charged with covering for a sick colleague. They read in the notes: “Client often acts inappropriately in session.” The coworker is left to their imagination to wonder if the client laughs inappropriately, makes sexual overtures, or lunges across the room unexpectedly. Mitchell (2007) labels this charting as using “conclusionary terms” without substantiation and goes further to imagine a client reading such powerful, potentially damaging documentation. Reamer (2012) suggests applying choice architecture, a decision-making framework used in business, to ethical
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