_____________________________ Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
their own reputation in jeopardy. The supervisor can further problem-solve the issue with the clinician and determine vari- ous potential causes of the late documentation. For example: • Does the clinician lack a knowledge base of what constitutes good documentation? • Do they struggle with time management such that the task of documenting remains undone? • Is their work with clients crisis-oriented, or do they have so many responsibilities that documentation does not rise to the top of the priority list? • Does the clinician lack the resources necessary to provide timely documentation? Documenting Supervision Reamer (2015) advises that supervisors, as evidence of oversight and monitoring, must document any supervision provided. The concept of respondeat superior (“the master responds”), the legal principle in which a supervisor can be held liable for actions or inactions of their supervisees, demands it. Documentation of routine supervision is one protective risk management strategy. Barnett and Molzon (2014) advise that informed consent be a foundational agreement when beginning supervision. As they describe, this agreement is no simple thing and should include: • Expectations, responsibilities, and obligations of both supervisor and supervisee; • Any fees and financial arrangements relevant to the supervisory relationship; • Scheduling and emergency contact information; • Documentation and record keeping requirements; • The use of any audio and video recording; • Evaluation and feedback to include the expectations and requirements for successful completion of the training experience; • Expectations for confidentiality and any reasonably anticipated limits to confidentiality; • Legal requirements such as mandatory reporting requirements, expectations for use of the supervisor and when the supervisee should contact him or her; and • Information about how and when the supervisory relationship will be ended (pp. 1052–1053). Barnett and Molzon (2014) also emphasize the importance of documenting each supervision session. They list several reasons for documenting supervision, including mitigating the possibility of misunderstandings, fostering accountability for both parties, aiding one in tracking the progress of professional development and clinical services, and using it as a risk man- agement tool to demonstrate that supervision has occurred.
The American Board of Examiners in Clinical Social Work (ABECSW) has guidelines for clinical supervision that address the documenting of supervision. Both Barnett and Molzon (2014) and the ABECSW suggest a contractual agreement be signed by both supervisor and supervisee, listing the purposes, objectives, and methods of supervision. The ABECSW posi- tion statement (2004) asserts: “The supervisor understands the responsibility to create and main- tain an ongoing record of the supervision. Records must be kept in accordance with state and federal laws as well as agency policy. Accurate and thorough record-keeping is an important aspect of job management and provides protection in case of a legal challenge to the quality of the services provided” (p. 26). The NASW (2017b) standards state: “Documentation is an important legal tool that verifies the provi- sion of services. Supervisors should assist supervisees in learning how to properly document client services performed, regularly review their documentation, and hold them to high standards. Each supervisory session should be documented separately by the supervisor and the supervisee. Documentation for supervised sessions should be provided to the supervisee within a reasonable time after each session. Social work regulatory boards may request some form of supervision documentation when supervisees apply for licensure. Records should be safeguarded and kept confidential.” Supervision/consultation is important for documenting ethi- cal decision making. It is important to consult with colleagues, including supervisors, in formulating an ethical decision, and it is equally important to consult about what to document in the process. The same principles used to document services to clients apply equally to documenting supervision.
DECISION MAKING IN DOCUMENTATION Case Study 7
During a session a client threatened to punch her former boyfriend’s present girlfriend in the face. The worker speculated whether this admission met the criteria for a duty to warn. She pondered whether to document the threat, thinking that if she didn’t document it there would be no chance of either her client or herself being hurt legally. After the client willingly provided her boyfriend’s number, she did call him and his girlfriend and provided the warning to both. She considers her ethical obligation met but still wonders if it is necessary to document the interchange. These questions guide the necessity to document: • For whom is the note written? (Is the information for the agency, the practitioner, collateral or subsequent practitioners, or the client?) • Is it necessary? (Does the information further the goals of treatment or link other aspects of treatment?) • Is it useful? (Does the information relate to the treatment goals, or is it extraneous?)
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