One suggestion is that a Delphi study method be undertaken to interview behavioral professionals who occupy positions on state licensing boards, particularly those who review ethical complaints against clinicians. In this type of potential study, researchers could compile expert opinions on the role that documentation plays in ethical complaints that result in penalties, without revealing protected health information, thus preserving the confidentiality of clients and patients (Harris et al., 2009). Another study recommendation is that a clinical scenario could be presented in a video format to a group of experienced clinicians and a group of newly licensed providers. Given this scenario, clinical documentation of the vignetter could be thus studied and compared along key observational points within the clinical records, such as assessments for suicidal ideation, homicidal ideation, or the presence of posttraumatic stress disorder. Research narratives could then isolate key differences between the two clinical groups, providing a rich observational view for publication (Harris et al., 2009). Additionally, authors suggest furthering this research approach by requesting input from legal professionals who could comment on risks that could emerge from violations within various case records. Documentation and Patient Care in a Digital World Mental health practitioners are increasingly making use of various forms of digital technology in their professional work from electronic health records, texting, telehealth, and online delivery of services, with advocates pushing for an expansion of technology to create greater access for patients (Magnavita, 2018; Maniss & Pruit, 2018). The American Psychological Association (APA) recognized that technology would change so quickly that references to specific forms of technology might have to be revised frequently. Thus, the choice was made to eliminate specific references in favor of broad-based terms and suggestions for security and protecting confidentiality, such as maintaining a separate psychotherapy note in an electronic health record. From marketing a practice on a website to using avatars in counseling, the use of digital technology and social media has changed the face of the counseling profession. Frederic G. Reamer, quoted in Pace (2014, p. 4), suggests that the use of technology “fundamentally alters the helping relationship.” He has researched the ethical challenges that can result from new interventions such as telehealth, email chat, social networking, texting, phone apps, and self- directed web-based healing modalities, going so far as to suggest that it is not inconceivable that a practitioner may never see a client in person (Reamer, 2013). Documenting services provided online or via telephone and clients’ access to such documentation have evolved more quickly than standards to guide or regulate the practice (NASW, 2017b). Using the axiom of “start where the client is,” a practitioner might justify engaging with adolescents via their preferred medium of electronic communication (Reamer, 2013). However, some ethical vignettes illustrate the ethical risk and emphasize the need for informed consent related to confidentiality and access limitations that using technology may pose. Texting has become more frequent in clinical practice. Despite the risk to client privacy and confidentiality, some clients - especially adolescents - prefer this mode of communication. Therefore, serving adolescent populations may involve texting, an issue that providers previously - say, 10 years ago - would have have likely considered an unlikely practice. Informed consent should address this risk. Should
Training and education can also enhance a clinician’s understanding of ethical and legal case documentation. Graduate programs in social work, marriage and family therapy, mental health counseling, and counseling psychology can greatly assist in this process by reviewing and revising, if necessary, their curricula to include coursework on state-level ethical and legal requirements for case documentation. If current graduate coursework is insufficient in this area, Harris and colleagues (2009) write that “students can be trained in case documentation within the classroom setting. Courses that focus on professional development, ethical, and legal issues, or clinical practices and procedures could all touch on clinical records” (p. 395). Supervisors can offer ongoing, weekly training sessions for new clinicians to help them understand practical requirements that must be met when creating a proper case record. However, supervisors may be deficient themselves in the knowledge required to adequately train in this manner. If this is the case, supervisors may be an important first group to evaluate for competency related to proper documentation practices. Additionally, legal professionals and seasoned providers can be contacted to organize potential training sessions to address statutory requirements and ethical precepts that new clinicians must observe (Harris et al., 2009). texts be included in the health record? The short answer is yes. Whether to include the exact text or a summary of the text discussion is at the discretion of the provider, but there should be some record of text communication (NASW, 2017b). Next, the expansion of electronic health records or electronic medical records is well underway in healthcare generally, and behavioral care specifically (Arauz- Boudreau et al., 2019). The majority of agencies are moving toward electronic record keeping. The burgeoning field and profession of health informatics encompasses the development and monitoring of electronic health applications (Nelson & Staggers, 2018). Private practitioners usually are not required to use electronic record keeping, but many are choosing to do so via various platforms and software packages. Financial record keeping related to the private practitioner’s experience becomes as important as clinical record keeping. Edgcomb (2022) summarized the digital advance into healthcare documentation, primarily child mental health in broad strokes as “adapting the EHR as a tool for health delivery provides an important avenue to support measurement-based care, improve communication between providers, patients, and families, and mitigate clinician burnout and fatigue. However, the promise of bridging these fields must be tempered with an understanding of the feasibility within the context of workforce shortages, need for protection of health information, potential for biases, and challenges ahead” (p. 11). Accuracy in billing records is a risk management safeguard against client complaints. It is recommended that such records include the date as well as the type and duration of services provided, with associated charges and dates of receipt of payment or third-party reimbursement. Complications arise when modifications are made to fee arrangements, such as sliding scales or other considerations regarding ability to pay. Documentation is particularly important to avoid misunderstandings or the appearance of preferential treatment. However, new technologies can also usher in the threat of potential cyberliability - a new concern for behavioral health providers.
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