The most salient risk in electronic record keeping is computer security and subsequent breach of client confidentiality when records are stored on agency servers or personal computers. Malpractice insurers list several ways in which technology breaches can put practitioners at risk, including losing a laptop or flash drive with stored client information, faxing or emailing information to the wrong recipient, or falling victim to cyberhacks on a data management system. Even if a data storage service loses the information, the practitioner can be held directly liable (NASW Assurance Services, 2018). In addition, using distance counseling platforms presents potential conflicts of interests. Clients may assume that practitioners endorse the advertisers and sponsors on the video counseling sites (Reamer, 2013). Electronic recording poses multiple risks. In her book on social work documentation, Liz O’Rourke (2010) paints a grim picture: “The power of databases to enable information about us to be shared by others in ways over which we have no control raises the spectre of Foucault’s Panopticon . . . the all-seeing Panopticon was a means to observe, control and discipline behavior . . . The social work record may be seen as part of the Superpanopticon, which is scrutinizing the service user, but at the same time it may also be a means to scrutinize the practitioner” (p. 31). Indeed, applying the metaphor of a panopticon (a building, usually a prison, designed in such a way that people can be observed at any time without their knowledge) to electronic documentation emphasizes that both the client and therapist need to consider that the information contained in a record may be viewed at any time by unknown parties. This awareness should serve to regulate what the therapist records about a client. Although extreme in nature, this metaphor does illustrate the importance of the caution practitioners need to apply when creating client records. The assumed scrutiny speaks to the need for proactive risk management protocols in record keeping and documentation. Both paper-based and electronic records are subject to breaches if access is easy (Bradshaw et al., 2014). Thus, the focus should be on securing records, either physically or through technology such as encryption. Although Reamer (2013) also speaks about the ethical risks of electronic documentation, he advises providers to document electronically in the same way as they would make a paper record because encrypted electronic records
are actually more secure than traditional charts. He does caution that any clinical encounters via electronic media (email, text, social networking, or telephone) should be charted in the case record. Behavioral health practitioners working for organizations rely on compliance and information technology professionals to provide secure computer network security systems. With respect to private practitioners, of course software programs and platforms must be HIPAA compliant, and records should be encrypted. In addition, practitioners are advised to ensure that their liability coverage includes digital documentation protection. Liability and billing insurers may also have recommended programs for private practitioners to use for electronic record keeping. Despite the extensive reach of HIPAA regulations, standardized measures to monitor electronic records and dissemination of confidential information have yet to be developed (Bradshaw, 2014). The duty of quality assurance (QA) programs is focused on service implementation and outcomes, with less focus on managing the quality of records. Internet Cognitive-Behavioral Therapy Innovative behavioral programming has been created and studied to investigate the effectiveness of asynchronous delivery of mental health services that aim to ameliorate symptoms of substance abuse, depression, anxiety, insomnia, and health anxiety. Online tools of this kind alter the documentation and treatment landscape and reflect the growing movement within healthcare to integrate technology in the service of patient needs, without inadvertently sacrificing ethical and clinical requirements (Axelsson et al., 2020; Richards et al., 2020; Sharif-Sidi et al., 2021). According to Sharif-Sidi and colleagues (2021), one such program sought to create greater access to behavioral care, thus overcoming identified obstacles such as stigma and cost. Researchers utilized a brief therapy format comparing online Internet cognitive-behavioral therapy (ICBT) to face-to-face cognitive-behavioral therapy (CBT) delivery, discovering that the two methods of clinical delivery measured approximately the same in terms of effectiveness. The authors emphasized the effectiveness of ICBT but cautioned that long-term studies are needed to understand if ICBT functions best as a bridge to other face-to-face treatment modalities or as a viable long-term treatment option.
CONCLUSION
The importance of clinical documentation rests firmly on the concept of accountability, namely, clinical, administrative, legal, and ethical responsibilities. Understanding what and how to document is the ethical responsibility of the practitioner. The complexities and nuances of clinical record keeping demand an informed approach, and certainly continuing education and training are essential. Documenting in the digital world requires particular attention. The rapid expansion of telehealth and online modalities has made this clear. Clinical records serve multiple purposes in the current healthcare arena. In particular, in the increasingly complex and litigious realm of mental health practice, the balancing act required for practitioners to document sufficient, necessary, and helpful information, with risk-management principles in mind, illustrates that clinical record keeping should not be taken lightly. The challenge for clinicians is to adhere to the profession’s values and ethics, while documenting client information and the therapeutic
encounter. Generally, documenting more process and less content is a good risk-management strategy. Records should reflect the clinician’s competence, intentionality, and decision-making process in weighing options; the rationale for treatment; and awareness of relevant clinical, ethical, and legal information. Given the pivotal role of record keeping in behavioral health practice, and the fact that it often takes up more than half of a practitioner’s time, creating an ethical and practical document is not adequately addressed in professional training (O’Rourke, 2010). The complex nature of healthcare documentation in the twenty-first century requires ongoing education. In a review of the APA’s revised record-keeping guidelines, Drogin and colleagues (2010) conclude that “record keeping issues are ever-present and are inextricably bound up in Ethics Code requirements, ignorance of which could lead to very serious consequences for everyone involved.
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