Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
life history includes childhood development, school, family and other significant relationships, employment, socioeconomic status, sexuality, and substance abuse. Exploration of the pre- senting problem requires an examination of the history 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 impor- tant 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, edu- cational, employment, and social history; and identifies client strengths and limitations, including risk and protective factors (Wiger, 2022). 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). 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. A medical analogy can illustrate the importance of such attentive record keeping: For a patient receiving a medication, the failure of the practitioner to record the setbacks, limitations, progress, plans, adverse effects, and clinical observations might cause the treatment to be futile or, worse, dangerous. The chances of the practitioner being accused of negligence would be high. To satisfy managed care insurers, progress notes are “expected to provide information about the client, the implementation of the intervention, and goal progress or attainment” (Kane et al., 2002, p. 204). Notations are best if they are documenting observable or measurable behavior. Acceptable progress notes include five elements (Kane et al., 2002): • The contact
• The client’s behavior and/or affect • Client reactions to interventions
• Reactions of others • Significant events
Ethical dilemmas in documentation arise in a managed care environment when protecting client confidentiality conflicts with disclosing sufficient information to satisfy managed care requirements. Progress notes are often organized in one of two recognized formats: SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan). Another format serves to help train novice workers: STIPS (Symptoms, Topics of discussion, Interventions, Progress and plans, Special issues). These struc- tured/semi-standardized formats assist providers in focusing documentation. CASE STUDY 2 Samantha is a client who has been receiving counseling from Darlene, a seasoned practitioner, for the past year. Samantha sought out Dar- lene’s services at the recommendation of her attorney following the state’s removal of her three children, ages four, six, and nine, due to severe neglect. At the start of treatment, Samantha explains that at the time of her children’s removal she was experiencing severe depression precipitated by the children’s father abandoning them and Samantha’s mother dying within the same month. The children’s removal further exacerbated her depression. Fourteen months later Samantha has stabilized, and reunification with her children has begun. It is expected that the children will return to her full custody in about three months.
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