_____________________________ Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
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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