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ETHICS IN BEHAVIORAL HEALTH DOCUMENTATION: REASONS, RISKS, AND REWARDS (MANDATORY) 1 [3 CE hours] This basic-level course will help practitioners approach documentation in a way that is guided not solely by what is mandated, but by what is mutually beneficial to all stakeholders in the documentation process: The practitioner, the agency, the funding source, and – most of all – the clients. THIS COURSE FULFILLS THE REQUIREMENT ON ETHICS 34 [15 CE hours] Anxiety disorders are characterized by states of chronic, excessive dread or fear of everyday situations. The fear and avoidance can be life-impairing and disabling. Anxiety disorders result from the interaction of biopsychosocial factors, whereby genetic vulnerability interacts with situations, stress, or trauma to produce clinically significant syndromes. The influence from hereditary factors and adverse psychosocial experiences on anxiety disorder pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying factors in the development and maintenance of anxiety disorders. ANXIETY DISORDERS SUBSTANCE USE DISORDERS: ASSESSMENT AND TREATMENT, 2ND EDITION 88 [6 CE hours] This intermediate-level course is intended for social workers, marriage and family therapists, mental health counselors, and psychologists. The course provides information on the scope of substance-related problems in the United States; the different categories of substances that are commonly abused and their neurochemical effects on the human brain and an individual’s biopsychosocial functioning; the major theories of addictions and different screening, assessment, and diagnostic instruments; the benefits and limitations of different intervention and evidence-based treatment approaches; and the unique needs of various populations affected by substance use disorders.
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PSYCHOLOGY CONTINUING EDUCATION
Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________ PYNC03ET — 3 CE HOURS R elease D ate : 07/10/2023 E xpiration D ate : 07/10/2027
Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
land Global Campus, teaching in the University’s First Term Experience department. Faculty Disclosure Contributing faculty, Matthew Lucas, MS, LMFT, has dis- closed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planners John M. Leonard, MDJohn V. Jurica, MD, MPHMargo A. Halm, RN, PhD, ACNS-BC, FAANRandall L. Allen, PharmD Senior Director of Development and Academic Affairs Sarah Campbell Division Planners/Director Disclosure The division planners and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Audience This course is designed for all licensed mental health providers. Course Objective The purpose of this course is to introduce the reader to the importance of ethical and intentional clinical documentation, and to provide strategies for documenting services that adhere to ethical guidelines and avoid risk. This basic-level course is intended for both novice and seasoned human service and healthcare professionals, including social workers, mental health counselors, marriage and family therapists, and psy- chologists. Learning Objectives Upon completion of this course, you should be able to: 1. Explain the rationale for high-quality documentation. 2. Describe the content of good clinical documentation. 3. Identify aspects of clinical documentation that present potential ethical problems. 4. Describe decision making in ethical documentation. 5. Discuss proper documentation within integrated care settings. 6. Recognize documentation risks specific to digital record-keeping. Faculty Matthew Lucas, MS, LMFT is a licensed marriage and family therapist practicing within an integrated primary care practice since 2015. He received a Masters of Science in counseling with an emphasis on marriage, family and child therapy from the University of Phoenix, Sacramento Gateway campus in Northern California. Additionally, he has maintained a pri- vate practice since 2011, and has previously directed several psychotherapeutic programs. Most notably, he developed and directed a brief therapy, partial hospitalization program for high-risk, self-harming adolescents. Mr. Lucas has completed on-going training in Jungian psychotherapy, and continues to study analytical concepts for treatment purposes. He is also an adjunct associate professor with the University of Mary-
Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psycho-
logical Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibil- ity for the content of the programs.. Designations of Credit NetCE designates this continuing education activity for 3 Ethics CE credits.
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About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners.
HOW TO RECEIVE CREDIT • Read the entire course online or in print. • Complete a mandatory test (a passing score of 75 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. • Complete the mandatory Course Evaluation.
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Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
What might she have done differently to avoid the upsetting response to her documentation? She had the option of not recording the client’s exact words and charting more about exploring his discouragement and frustration. She could have included more about her suicide assessment and her conviction that he was not a danger to himself. So, in this instance, either documenting more or documenting less could have influenced the outcome considerably. Practitioners usually know what is minimally required in documentation; however, what is least required may differ significantly from what is recommended or optimal. Optimal documentation includes information that is relevant to the clinical services being provided and that addresses legal, ethi- cal, and administrative obligations. Agency practice and time demands often result in practitioners documenting only what is required. This practice may leave the agency and practitioner open to scrutiny and risk, and at the same time shortchange the client’s services. This basic-level course will help practitioners approach documentation in a way that is guided not solely by what is mandated, but by what is mutually beneficial to all stakeholders in the documentation process: The practitioner, the agency, the funding source, and - most of all - the clients. Graduate training rarely includes course content on documen- tation skills (Leon & Pepe, 2013). Sidell (2015) recommends that behavioral health professionals begin their careers well prepared to document, but often they do not. Historically, only six texts were written about case documentation from 1920 to 2008, and limited attention is given to it in practice texts (Sidell, 2015). Although graduate education requires that the field placement or practicum experience teach documentation skills, documentation requirements may differ according to the agency setting and may or may not be equally applicable across professional settings and roles. Often practitioners are left to learn the complexities of appropriate documentation on the job, and their work is often supervised by individuals with perhaps limited training on documentation. Leon and Pepe (2013) suggest that one way to close this gap is to provide more continuing education workshops that help to “develop and maintain those essential skills” (p. 116). This will be discussed later in this course. Their study on the effects of a two-part continuing education documentation workshop for hospital psychosocial staff members showed a significant increase in staff knowledge of documentation in the areas of progress notes and discharge summaries. The authors point out the scarcity of research on reliable and valid documentation measures and underscore the need for more continuing education and research in this area. Based on their evaluation of a documentation workshop, Dziegielewski and Holliman (2019) also demonstrated a need to train indi- viduals in all disciplines on issues of documentation regardless of their professional license. To help fill the void in training on documentation found by several authors, this course illuminates the complex nuances of writing for the clinical
INTRODUCTION Proper documentation is based on the standard of accountabil- ity. Too many clinicians receive minimal training in this area, despite its central role in behavioral health practice (Reamer, 2009; Sidell, 2015). The lack of knowledge and skill regarding documentation is a potential liability. Documenting according to ethical standards is therefore relevant to all clinicians. With technological advances, digital documentation has increasingly become the norm; however, electronic health records and other forms of electronic communication pose ethical risks in docu- menting services. For social workers, counselors, marriage and family therapists, and psychologists, documentation is equally important before, during, and after a clinical encounter. A common adage states: “If it isn’t written, it didn’t happen.” Although documentation serves multiple essential purposes, it is fraught with risk and liability. Sidell (2015) advises that proper documentation is one way to protect clients, practitioners, and the organization. Kadushin (1972), a pioneer who authored seminal works on the mental health encounter, suggests that “the interview begins before it starts” (p. 106), meaning that clinicians often formulate impressions and speculations about clients or patients before they ever speak to them in person. For example, paperwork is often completed by an intake or clerical staff worker long before the clinician actually meets with clients in person for the first time. This preliminary documentation may direct the assessment and treatment process. What is written about the client may appropriately assist the practitioner, or conversely, it may provide a detour from providing the best treatment. Imag- ine that a medical technician inaccurately records a patient’s blood pressure and that the patient is put on medication for hypertension unnecessarily, has a reaction to the medication, and dies. In response to the tragedy of an unnecessary death, the family sues the practitioner and practice agency; as a result, several lives are changed forever. Although this example is an extreme worst-case scenario, equally harmful documentation missteps are possible in the behavioral health field. A social worker on a specialty cardiac unit speaks with a client who is tethered to a left ventricular assistive device (LVAD) while waiting for a transplant. In her attempt to be accurate in documenting their conversation, she charted the client’s exact words: “Sometimes I just want to pull the plug.” She continued to assess for suicide and deemed that the patient was not in imminent risk but just feeling understandably discouraged some- times. She charted, “We processed his emotions and ambivalence living with an LVAD.” When other team members read her note, a psychiatric emergency evaluation was arranged, which upset the patient even more. He told the social worker, “You knew what I meant. I wasn’t going to kill myself. I will never confide in you again!”
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record and assists the practitioner in determining when, what, and how much to document. In addition, summaries related to documentation from the codes of ethics of the American Association of Marriage and Family Therapy (AAMFT), the American Counseling Association (ACA), the American Psychological Association (APA), the National Association of Social Workers (NASW), and National Board for Certified Counselors (NBCC) are included in the Appendix. THE RATIONALE FOR DOCUMENTATION Frederic G. Reamer (2009), one of the architects of the current NASW code of ethics, describes documentation as one of the most important skills in behavioral health practice. The clini- cal need for thorough, accurate, and timely documentation to ensure quality service delivery cannot be overemphasized. In addition, given the growing demands of managed care and utilization review, documentation is increasingly more important in healthcare settings as accountability, clinical accuracy, and treatment outcomes determine funding and the level of authorized services. The NASW Code of Ethics (2017a) reflects the impact of swift technological change on practice, including treatment options as well as storing, retriev- ing, and documenting client data, particularly in electronic health records. The vignettes included in this course are designed to illustrate many of the reasons for good clinical documentation, as well as some of the ethical risks, fears, mistakes, and myths of documenting in the helping professions. What drives docu- mentation? Who is it for? Whose interest does it serve? Record keeping is a safeguard for both practitioners and clients. Good clinical documentation primarily meets the needs of the cli- ent, practitioner, and agency; however, it is also intended to meet the needs of the supervisor, professional boards, regula- tory organizations, and accrediting bodies. O’Rourke (2010) provides a unique perspective in describing the record as an “exercise of observation and interpretation of the clients’ behaviour” (p. 29). As such, it affords the practitioner power, often focusing solely on the client, not on the interaction of the client and clinician. Access to records by - clients, agen- cies, and courts - serves to diminish this power by providing a window into the behavior of the practitioner. The power resides in the recorded information. Kagle and Kopels (2008) suggest that clinical record keeping has primary, secondary, and sometimes tertiary functions. The primary function is to satisfy accountability, and its secondary purpose is to support practice and professional education. Tertiary functions of record keeping involve research and data analyses. How does the record represent the organization’s and practi- tioners’ values? The values of beneficence, nonmaleficence, autonomy, justice, and fidelity are often cited as basic principles undergirding an ethical decision-making standard of care in behavioral health. Common questions include:
• Do the records reflect those values? • Is what is documented in the best interest of the client (beneficence)? • Does the documentation do no harm? (nonmaleficence) • Does it reflect fidelity (loyalty, integrity, truthfulness)? • Do the records indicate protection of a client’s self-determination (autonomy) and fairness, nondiscriminating language, and equal service (justice)? Good record keeping entails more than repetitive paperwork required by organizational, state, and federal regulations. Bodek (2010) offers seven purposes of documentation, all of which have ethical implications. 1. To document professional work; 2. To serve as the basis for continuity of care by the treating provider; 3. To serve as the basis for continuity of care for subsequent providers; 4. To manage the risk of malpractice complaints and assist in the defense of such complaints; 5. To comply with legal, regulatory, and agency requirements; 6. To facilitate quality assurance; and 7. To facilitate coordination of care among members of the treatment team. There are clinical, administrative, and legal domains of provid- ing mental health services, all of which are related, overlap- ping, and affected by ethical documentation. Each of these related domains, and the rationale for their documentation, is discussed in turn. CLINICAL RATIONALE Record keeping is both a process and a product. Although there is overlap, the process of recording generally serves as a guide for the clinician and client; the clinical elements in a client’s record can provide guidance for the practitioner about the direction of the client’s ongoing or future therapeutic work, and the product of documentation serves as proof of this clini- cal interaction for administrative purposes. Professional record keeping allows for good care; assists collaborating professionals in delivery of care; ensures continuity of professional service; ensures appropriate supervision or training; provides requisite documents for reimbursement; and documents decision mak- ing, especially in high-risk situations. Ideally, the process of documenting serves as a quality assur- ance tool by making clinicians reflect upon and evaluate their clients and their work. Quality record keeping of clinical services is valuable in facilitating quality treatment. “Through the recording process, which involves selecting, reviewing, analyzing and organizing information, the practitioner comes to a better understanding of the client-need-situation” (Kagle & Kopels, 2008, p. 10).
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In addition to being the compilation of case history and activ- ity, records provide a planning tool for future interventions with a client. Most practitioners have large caseloads and need to rely on records for keeping track of case information and details. Notes allow the clinician to discern patterns of behavior or interpersonal styles that can direct treatment. Clinical documentation can also be used to monitor and track treatment progress. Extreme views on the importance of documentation suggest that the quality of the record will reflect the quality of the care. Additionally, documenting is an important tool in clinical skill development for the training and education of behavioral health providers. Professional social work, for example, has historically relied on the case method and process recording as a means to train students in “communication and relation- ships, and processes of assessment, intervention, and evalua- tion” (Kagle & Kopels, 2008, p. 17). Diagnostic Impressions Records typically include the client’s relevant history and the clinician’s diagnostic impressions - which are usually revealed within the first few sessions. Some practitioners prefer not to attach labels to people, particularly their clients. Although this approach may seem altruistic in some ways, it can be misguided. Providing a presumptive diagnosis may assist the practitioner in developing a blueprint for treatment and guid- ance in selecting best practice interventions for a particular disorder. Bodek (2010) warns that the lack of a thorough initial assessment is likely to result in inadequate or inappro- priate treatment. In some instances, the client may appreciate that there is a label to validate what they are experiencing. Identifying the problem will help determine the treatment and cure. However, strengths-seeking, solution-focused, feminist, and humanistic practitioners prefer to look at what is “right” about the client’s functioning and behavior, and often view diagnoses as pathologizing what could be considered adaptive behavior (Solomon, 2021). In light of the managed care environment, a diagnosis may be considered a “necessary evil” because reimbursement for services from health insurance companies can be secured only for a “billable” diagnosis (Patel et al., 2021). Prior to authorizing treatment, some managed care organizations may also require documentation of client need based on diagnosis. Those clinicians reluctant to diagnose because they feel it is too pathologizing might try to reframe diagnosing as providing the rationale for the clinician’s and client’s choice in treat- ment approaches, including strengths-based, client-centered treatments. Clinicians who choose not to accept insurance reimbursement are still professionally obligated to provide adequate documentation of services provided. Clinical Guidance Clinical documentation has typically aligned with the medical model, a colloquial term for the taxonomy of causalism, in which a linear causality of pathology is sought and described.
The term medical model contrasts with behavioral health concepts of holism. Although the holistic strengths-based view is compatible with the profession’s most fundamental principles of practice, it is incompatible with the traditional disease-oriented focus of the medical profession. The medical model is further reflected in the traditional problem-oriented medical record (POMR), which documents treatment accord- ing to each “problem/diagnosis” assigned to a client. Practi- tioners are forced to focus on problems rather than solutions. The medical model relies almost exclusively on documenta- tion to reflect patients’ needs, services, and progress (Leon & Pepe, 2013). Clinicians face challenges documenting in ways that represent a shift from a medical model to health-oriented and strengths-based paradigms (Braun, Dunn, & Tomcheck, 2017; Weick, 2009). Behavioral health, particularly social work, extends the medical model to add contextual informa- tion relevant to the patient’s needs, services, and progress. Of course, diagnostic impressions are not just clinical diagnoses, and thorough assessment of the client’s situation is not cap- tured with only a diagnostic label. ADMINISTRATIVE RATIONALE One of the primary functions of documentation is to create and provide a central record for all collaborating providers. This record is used for clinical purposes and, increasingly, for administrative purposes (Mulholland & Healy, 2019). Third-party requirements such as the funding stipulations of managed care or regulatory bodies for accreditation are often the driving force behind documentation. Additionally, funding sources are demanding more evidence-based practice (EBP) and outcome-oriented interventions. Documentation practices are following the emergence of EBP, thus helping treatment approaches and outcomes appear in a clear docu- mented form. Increasingly, funding streams require proof of EBP for approval and reimbursement of services. Funding sources look for accountability of monies allocated through evidence of service effectiveness. Three areas in which EBP is supported by documentation are client needs and presenting factors, services (treatment activities), and client outcomes, thus creating a precise record of patient-related events. A major administrative reason for documentation is to satisfy managed care utilization review requirements. Records are reviewed prospectively for authorization of services, concur- rently for monitoring services, and retrospectively for billing purposes or report-writing. Interestingly, ethical concerns have increased in the managed care milieu as the restrictions imposed by “managing” care are perceived as “limiting” care and the temptation to embellish records to justify even mini- mal care presents itself as an option. Critical incidents often showcase the advocacy skills that are needed to confront the funding restrictions which govern what is considered necessary and what is authorized (Kane et al., 2002). When securing continued services, the clinician must advocate for the client, rather than inflating the records or the problems documented within them.
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Program Accountability Administratively, records can provide accountability on several levels: To the client, funding sources, the organization, regu- latory bodies, and the profession (Ramanuj et al., 2019). In an ideal world, records might also provide quality assurance. Treatment is normally not observed by a third-party evaluator; thus, records may provide an indirect window through which to observe and monitor the quality of service. Lastly, records provide the means for securing resources; that is, documenting “billable” services serves to substantiate reimbursement and can also justify the need for additional services. Good documentation provides cumulative data that can be used to demonstrate gaps in service delivery or in the continu- ing education needs of staff. The data can be used to evaluate program effectiveness and demonstrate successes. Accrediting and regulatory bodies rely almost exclusively on records to provide oversight and assessment of agency efficiency and qual- ity. This aspect of documentation lends itself to a high risk of ethical violation, as staff may be instructed or encouraged to “write for the reviewer,” and the temptation to falsify or alter records is high. The unethical practice of backdating notes or embellishing data to secure funding or accreditation may be rationalized by thinking, “If we don’t get the funding, we can’t continue providing service.” Records also meet the needs of the management team, as they are often used to assist in workload planning and distribution, and for internal reviews to evalu- ate compliance with both internal and external stipulations. Supervision Good record keeping not only protects the client and the process but also facilitates the practitioner’s professional development. A supervisor’s review of records is a valuable tool for evaluating and remediating the knowledge and skills of the practitioner. In a strong supervisory relationship, the supervisor will use the supervisee’s documentation to highlight noteworthy aspects of a particular case or assess the practitio- ner’s caseload (Kagle & Kopel, 2008). In contrast to the more common use of records to demonstrate inadequacies, this approach uses the record constructively to encourage reflection and ultimately improve practice. Sidell (2015) emphasizes that documentation should remain a topic in supervision. It should be valued as a skill, equal to any clinical skill in the worker’s repertoire. Furthermore, because of liability concerns, supervisors should document supervi- sory encounters with supervisees. However, documenting the supervision itself is a commonly neglected task. Although supervisors may demand thorough documentation of clinical encounters from their supervisees, supervisors often give far less attention to documenting their own work with staff. In the spirit of parallel process, supervision sessions should be documented for the same reasons that client interaction is documented.
Supervisors should document time, date, and content of super- visory sessions. Mental health administrators should document any discussions pertaining to ethical decision making. As mentioned, all supervision encounters should be docu- mented (Association of Social Work Boards, 2009; Barnett & Molzon, 2014). Recording supervision protects supervi- sor, supervisee, the organization, and – indirectly - clients. Although supervisors may stress the importance of document- ing clinical services by their supervisees, equal emphasis on documenting supervision is not common practice. According to Barnet and Molzon, documentation of supervision can “(a) help reduce the chance of misunderstandings occurring, (b) help increase accountability on the part of the supervisee, (c) be an excellent aide for both parties when reviewing to track progress both of the supervisee’s clients and the supervisee’s professional development, and (d) serve an important risk management role in providing a tangible record of what has transpired in supervision and the supervisor’s efforts so provide high-quality clinical supervision” (2014, p. 1057). Themes noted, cases discussed, educational needs, and supervisor’s impressions and recommendations are all appropriate content for a supervision note. Documenting supervision for licensure purposes is particularly important for potential audits. Sidell (2015, p. 191) proposes a guide to structure supervisory notes using the acronym SUPERS: S - supervisee-initiated items U - useful feedback or suggestions from the supervisor PE - performance expectations that have been discussed R - recommendations for future goals S - strengths of the supervisee Sidell also provides a sample format for documenting group supervision that records date, participants, topics explored, follow-up, and next meeting. Administrative Compliance Of the seven purposes of documentation identified by Bodek (2010), the last four could be viewed as administrative in nature. Again, these purposes are: • To manage against the risk of malpractice complaints and to assist in the defense of such complaints; • To comply with legal, regulatory, and organizational requirements; • To facilitate quality assurance; and • To facilitate coordination of care among members of the treatment team.
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Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
CASE STUDY 1 In discussing copayments with a group of colleagues, one mental health clinician at an agency that offers no sliding scale or reduced fee revealed that when a copayment is very high (e.g., $50) and the client is obviously struggling financially, she often reduces the co-payment, taking less money for herself as a result. However, she enters the higher amount (which she didn’t take) in her records and keeps knowledge of the reduced fee between herself and the client. The organization is still reimbursed for the session by the insurance company for the usual amount, which does not include the copayment. This scenario presents risks on all three levels: Clinical, administrative, and legal. Clinically, the worker is trying to do something helpful for the client, but Reamer (2009) suggests that altruism is frequently at the root of the unethical situations in which practitioners find themselves. What if other clients somehow discover this practice and perceive it as preferential treatment? Will they expect the same? Will the client interpret this as having a “special” relationship with the clinician? Will the client feel indebted to the clinician for the reduced fee? Administratively, the mental health clinician’s actions could be seen as deceptive bookkeeping practices. If the worker’s supervisor learns of the practice, might they question other documentation provided by the worker? Legally, could an argument be made that insurance fraud is being perpetrated? LEGAL RATIONALE Mental health professions have not escaped the increasingly litigious reach of our society, and proper documentation can establish the competency and qualifications of the provider. Accurate record keeping is the best protection from baseless claims. Careful documentation may mean the difference between a legal judgment for or against a worker or an organiza- tion (Moline et al., 1998). Legally, records protect the provider by demonstrating that the treatment provided was within the professional standard of care. Thorough records assist in clarifying and justifying questionable actions by the provider or organization. In fact, the NASW (2018) lists documentation clarity in the practitioner’s notes as one of the organization’s tips for avoiding malpractice. Obtaining informed consent is not a perfunctory obligation of documentation. There are challenges and risks associated with improperly obtained informed consent (Kilkku & Halko- aho, 2022). Although it is a legal and ethical requirement in healthcare, true informed consent is difficult to obtain and substantiate. The client’s level of understanding and decision- making capacity can vary across time and situations. Although a client may give consent for disclosure of information, for example, that disclosure may inadvertently backfire, possibly causing the client harm. Clients may be harmed by released health information that is improperly disclosed by the third- party recipient or when the information is used against them in a court proceeding. Even if information is properly released and disclosed, the information now made public may have residual effects for the client.
Liability insurers report that the most frequent licensing board complaints stem from perceived conflicts or damages resulting from divorce. When therapists are involved in seeing couples, this risk is salient. To obviate this risk, it is recommended that practitioners “create a documented record of resistance to disclosure” (NASW, 2018, p.1). This added informed consent requires signatures from all parties permitting the practitioner to resist disclosing records in good faith. In couples therapy this statement of neutrality protects the practitioner from being drawn into “taking sides” (e.g., of having records subpoenaed to harm the other partner). In essence, the statement explains that the practitioner is an “unbiased intermediary…and shall not act as an advocate for or against any party” (NASW, 2018, p. 1). In determining what is reasonable and customary for the public to expect from a particular profession, the courts look to the “industry standard” for guidance. Most “standards of care” are outlined by a profession’s code of ethics. Several organizations’ professional codes of ethics are recognized as the “industry standard” within the helping professions. These include the codes issued by the American Psychological Association (APA), the National 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 practitio- ners 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.
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_____________________________ Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
1. Content 2. Language 3. Credibility 4. Access
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 documenta- tion 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 col- leagues 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. • Write what could be comfortably shared with the client. • Write records logically. Ensure that charting has some relevance to the presenting problem or the guiding treatment plan. If charted information is not pertinent to either, it should not be included. “Usefulness requires specificity, and vague writing might be construed as indicating incompetence” (p. 31).
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 condi- tion” 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 poten- tially 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. Nonfea- sance 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.” Content of Documentation Good documentation requires organization, decision making, critical conceptualization, and effective writing. Good clinical documentation has specific elements of organization and writ- ing (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
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Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
• Avoid modifiers (such as soon or sometime) that are abstract or could leave room for doubt. Ultimately, according to Mitchell (2007), records should be understandable and accountable. Although HIPAA does not specify what is required in a medical record, according to Groshong and Philips (2015), the follow- ing must be included to meet behavioral health guidelines. • Billing information and payment records • Formal evaluations • Collateral contacts, including release of information (ROI) for all • Records from other providers with ROI • Counseling session dates, with start and stop times • Modalities and frequency of treatment • Medications • Diagnoses • Functional status (activities of daily living [ADL], ability to work, interpersonal capacity) • Medical/physical problems • Community contacts, including phone calls,
• Demographic information, including insurance and referral information • Intake information, including assessment, evaluation, and initial history • Service or treatment plan • Progress notes • Referrals or consultations made, collateral reports, and test results • Correspondence from other practitioners • Correspondence with patient or collaterals • Billing records • Informed consents/authorizations or other privacy- related information releases Consents and authorizations do expire, so records should con- tain original and updated forms so that the history of consent to services, communications, and such is evident (Hoffman & Herveg, 2021). In addition, it is recommended that a Health Insurance Privacy and Accountability Act (HIPAA) compli- ance folder for each patient be maintained separately from the patient’s clinical record and psychotherapy notes. Another organizing framework, offered by Sidell (2015), for a thorough clinical record includes the following five categories.
emails, or texts
1. Identifying information 2. Consents and releases
• Treatment plan and goals • Symptoms and prognosis • Progress in each session • Disclosure forms and informed consents signed by licensed professional and client • Presenting problem(s) or purpose of visit • Referrals to and results of formal consults • Progress notes sufficient to support responsible clinical practice for the type of orientation/therapy used All digital medical records should be backed up regularly and kept in encrypted format, with frequent changes in passwords. Although there can be both medical record and psychotherapy notes, information cannot be put in psychotherapy notes to avoid putting it in the medical record (Groshong & Phillips 2015). OVERALL CHART ORGANIZATION Chart organization and content may differ across settings. Organizations can require specific and structured information, whereas private practitioners have more flexibility as to order and organization. Bodek (2010) provides a framework for organizing a patient record for healthcare settings and advises that a file folder exclusive to each patient be maintained. The folder would consist of:
3. Assessments and treatment plans 4. Progress notes and service reviews 5. Communication with and about clients
In the early days of psychosocial intervention, the purpose of documentation was client service delivery. As patients’ rights gained prominence in the 1980s, the importance of clients’ rights to privacy was recognized. The 2003 passage of HIPAA actually legalized parameters of documentation content, such as confidentiality, informed consent, and distribution. HIPAA regulations have affected how client records are organized and what may be included. Documentation is often considered synonymous with record keeping; however, documentation encompasses many aspects, formats, and types of record keeping. To distinguish among the various types of records, the following definitions are offered. • Mental health records: These are patient records related to the evaluation or treatment of a mental disorder. These records include substance abuse (drugs and/or alcohol) records (Moline et al., 1998). Typically, behavioral health documentation is noted in a separate section of the electronic health record (EHR).
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