Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards _____________________________
• Is it sufficient? • Is it true? • Who might read it? • Who should/could read it? • Are there jurisdictional statutes that require it? And perhaps the most important question: • What might happen if I don’t write it? The concept of negative responsibility is the ethical notion that a person is equally responsible for inaction as for action. Negative responsibility plays into deciding what to document and what not to document. The skill of conceptualizing impor- tant themes without potentially damaging detail develops over time with experience. Mitchell (2007) expands on this concept by assuming the voice of a coworker when documenting. If a coworker was to read the note, would they find it sufficiently clear to ensure continuity of care? A client is not served well when a coworker is chal- lenged to interpret incomplete records. Suppose a coworker is charged with covering for a sick colleague. They read in the notes: “Client often acts inappropriately in session.” The coworker is left to their imagination to wonder if the client laughs inappropriately, makes sexual overtures, or lunges across the room unexpectedly. Mitchell (2007) labels this charting as using “conclusionary terms” without substantiation and goes further to imagine a client reading such powerful, potentially damaging documentation. Reamer (2012) suggests applying choice architecture, a decision-making framework used in business, to ethical deci- sion making, and it can be further applied to decisions about documentation. Choice architecture, a concept that originated in the economics and business fields, has recently appeared in the behavioral sciences literature. Choices are constructed in much the same way that steps are placed in strategic areas of building construction, and the placement of the steps them- selves then influences the choices people make. The concept of choice architecture can be used to assist in determining what to document in a clinical record. The con- cept advises that a clinician should expect error and manage the risk. The architecture of choice in ethical decision making applied to clinical record keeping suggests that the clinician should ask: • What would happen if I don’t document? (Do nothing.) • Should I consult? (Who should/could be involved in this decision?) • What if . . .? (Always anticipate errors and the need for risk management.) In building a case for documenting, the default decision is to do nothing. This decision certainly has its risks. Ideally the next step is to get feedback. The ultimate step is to expect error and manage the risk.
Reamer (2009) provides an ethics audit tool to manage risk in an agency in multiple areas. Documentation is one area the ethics audit addresses in which practitioners’ documentation styles and procedures should be assessed. The audit notes whether documentation routinely includes the following components. • Social history, assessment, and treatment plan • Informed consent • Collateral contacts • Multidisciplinary consultation • Justification for choice of intervention • Critical incidents • Recommendations to the client • All contacts with clients, including type, dates, and times
• Failed or missed appointments • Previous relevant medical history
• Billing information • Termination notes
In addition, documentation should be evaluated for anything that might imply defamation of character, including libel. “Social workers can be liable for defamation if they say or write something that is untrue, they knew or should have known to be untrue, and caused some injury to the plaintiff” (Reamer, 2015, p. 141). DOCUMENTATION DECISIONS: THE ETHICS OF DIAGNOSTIC CODES FOR CHILDREN Professional division exists within behavioral health when considering the utility of recording diagnostic codes for child patients. Researchers are investigating anew the clinical utility of traditional diagnostic criteria, namely the criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). These authors are investigating the usefulness of alternative diagnostic criteria that identify mental health and mental ill- ness as being found within a continuum of functioning and circumstances, not within the circumscribed categories that are often associated with the DSM and the ICD (Cartwright, 2018). Cartwright highlights the concern, stating that “clini- cians have recognized that the current categorical approach implies a discontinuous nature of mental health and does not allow recognition of the full spectrum and complexity of psychiatric disorders” (Cartwright, 2018, p. 196). According to Cartwright (2018), ethical decisions abound when considering diagnostic decisions because “children are especially difficult to diagnose given that neurodevelopmen- tal periods are not specifically defined, development among children varies widely, symptom patterns are difficult to detect within a short history, and children are reactive to family and environmental stress” (p. 196). Specifically, this problem is evi- dent when clinicians, using categorical diagnostic criteria, try to
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