_____________________________ Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
Samantha is looking forward to the transition, but she is also scared and anxious about being overwhelmed with parenting responsibili- ties. Samantha meets with Darlene weekly, and Darlene is in regular contact with Samantha’s case worker, attorney, and children’s therapists. Samantha and Darlene have discussed openly the limits of confidentiality in her therapy, and Samantha, at times, chooses to withhold information from Darlene that might reflect negatively in her client record because she knows it will be viewed by other profession- als involved in her family’s care. She has been reluctant to share the extent of her anxiety about the upcoming transition; however, Darlene is familiar with these types of reunifications and is able to normalize Samantha’s concerns and introduce salient interventions without Samantha having to feel overexposed. At their most recent session, they discussed Samantha’s relationship with her boyfriend, who has recently lost his job and is at risk of losing his apartment and antici- pated possible changes to the relationship as the children return home. In addition, they reviewed self-soothing and relaxation techniques for Samantha to use during times of increased anxiety, problem-solved parenting dilemmas, and discussed some of Samantha’s friendships. The following is an example of the progress note for this ses- sion using the SOAP format. S – Client reports looking forward to her children returning home and says that her boyfriend and friends are excited for her. She reports that her weekend visit with the children went very well, although she is worried that her nine-year-old has been getting into a lot of trouble in the foster placement. O – The reunification efforts have included increasing Samantha’s unsupervised time with all three children at once. A primary social support of Samantha’s is experiencing stressors that have impacted the relationship. Samantha neither confirmed nor denied that she is experiencing increased stress. Samantha is concerned about her oldest daughter. A – This time of reunification typically includes an increase in parental stress. While Samantha did not endorse feeling an increase in stress based on previous discussions, I suspect this is because she does not want to do or say anything that will jeopardize the reunifica- tion. As the experience of increased stress was normalized, Samantha wanted to revisit previous stress management skills. She continues to show determination in demonstrating behaviors that would lead to reunification. She thoughtfully engaged in a discussion about analyz- ing various social supports and their usefulness to her during this important time. The session ended with Samantha asking for help in problem-solving her concerns about her daughter. P – Continue to meet with Samantha weekly to prepare for the upcoming reunification, fortify stress management, social, and par- enting skills. How did Darlene navigate the various confidentiality concerns in this progress note? Confidentiality was protected with no identifying information about collaterals disclosed. The lan- guage is not harming, discriminatory, or judgmental, with a tone of identifying progress and strengths.
Wiger (2022) outlines common problems with progress notes, including vagueness, irrelevant information, and inability to elicit essential information from uncooperative clients, all of which can lead to ethical issues. In addition, taking shortcuts in documentation, such as not charting a separate note for each member attending a group or family therapy session, can be problematic. A simple framework for objectively assessing clinical notes is that another reader should be able to answer the following questions (Martha St. Enterprises, Inc., 2009): • What brought the client to seek help? • What was done about that presenting problem? • What were the interventions and results? • What was the disposition? INFORMATION FROM OTHERS Documenting information received from collateral contacts varies according to the purpose of the information and the manner and setting in which it is received. Likewise, child custody evaluations and investigations of domestic violence rely on third-party information (Henry, 2018). Documenting third-party information is a significant aspect of clinical record keeping in these situations. Parents or other caregivers are almost always involved in coor- dinating a child’s care in terms of scheduling appointments or coordinating with other providers. All of these contacts must also be recorded in a client’s record. Clinicians will also encounter collateral information under less life-altering circumstances, however. For example, a relative of a client leaves a voicemail for the therapist providing unsolicited, potentially important, possibly damaging, information. Is it necessary for the clinician to document anything? The decision concerning whether to document material received by collateral informants is based on clinical, legal, and therapeutic determinants. In some instances the information may be clinically important, and the information could have potential legal implications. The therapist’s records could be involved if there is a civil suit. One might be tempted to ignore the unsolicited information. However, not discussing or documenting the call also carries risk. To cover all bases, it would be prudent for the therapist, first, to recognize that she does not have a duty to keep the grandmother’s disclosure confidential. If the grandmother had spoken directly to the therapist rather than leaving a message, the therapist could have advised the grandmother that her disclosure is not con- fidential. In addition, without the consent of the client, the therapist can neither confirm nor deny that her grandson is a client. Next, the therapist should discuss the phone call with her client and document the results of that discussion. The therapist is then in a better position to assess the reliability of the information, its potential significance for the therapeutic work, and liability risk.
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