_____________________________ Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
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). In addition to being the compilation of case history and activ- ity, records provide a planning tool for future interventions with a client. Most practitioners have large caseloads and need to rely on records for keeping track of case information and details. Notes allow the clinician to discern patterns of behavior or interpersonal styles that can direct treatment. Clinical documentation can also be used to monitor and track treatment progress. Extreme views on the importance of documentation suggest that the quality of the record will reflect the quality of the care. Additionally, documenting is an important tool in clinical skill development for the training and education of behavioral health providers. Professional social work, for example, has historically relied on the case method and process recording as a means to train students in “communication and relation- ships, and processes of assessment, intervention, and evalua- tion” (Kagle & Kopels, 2008, p. 17). Diagnostic Impressions Records typically include the client’s relevant history and the clinician’s diagnostic impressions - which are usually revealed within the first few sessions. Some practitioners prefer not to attach labels to people, particularly their clients. Although this approach may seem altruistic in some ways, it can be misguided. Providing a presumptive diagnosis may assist the practitioner in developing a blueprint for treatment and guid- ance in selecting best practice interventions for a particular disorder. Bodek (2010) warns that the lack of a thorough initial assessment is likely to result in inadequate or inappro- priate treatment. In some instances, the client may appreciate that there is a label to validate what they are experiencing. Identifying the problem will help determine the treatment and
cure. However, strengths-seeking, solution-focused, feminist, and humanistic practitioners prefer to look at what is “right” about the client’s functioning and behavior, and often view diagnoses as pathologizing what could be considered adaptive behavior (Solomon, 2021). In light of the managed care environment, a diagnosis may be considered a “necessary evil” because reimbursement for services from health insurance companies can be secured only for a “billable” diagnosis (Patel et al., 2021). Prior to authorizing treatment, some managed care organizations may also require documentation of client need based on diagnosis. Those clinicians reluctant to diagnose because they feel it is too pathologizing might try to reframe diagnosing as providing the rationale for the clinician’s and client’s choice in treat- ment approaches, including strengths-based, client-centered treatments. Clinicians who choose not to accept insurance reimbursement are still professionally obligated to provide adequate documentation of services provided. Clinical Guidance Clinical documentation has typically aligned with the medical model, a colloquial term for the taxonomy of causalism, in which a linear causality of pathology is sought and described. The term medical model contrasts with behavioral health concepts of holism. Although the holistic strengths-based view is compatible with the profession’s most fundamental principles of practice, it is incompatible with the traditional disease-oriented focus of the medical profession. The medical model is further reflected in the traditional problem-oriented medical record (POMR), which documents treatment accord- ing to each “problem/diagnosis” assigned to a client. Practi- tioners are forced to focus on problems rather than solutions. The medical model relies almost exclusively on documenta- tion to reflect patients’ needs, services, and progress (Leon & Pepe, 2013). Clinicians face challenges documenting in ways that represent a shift from a medical model to health-oriented and strengths-based paradigms (Braun, Dunn, & Tomcheck, 2017; Weick, 2009). Behavioral health, particularly social work, extends the medical model to add contextual informa- tion relevant to the patient’s needs, services, and progress. Of course, diagnostic impressions are not just clinical diagnoses, and thorough assessment of the client’s situation is not cap- tured with only a diagnostic label. ADMINISTRATIVE RATIONALE One of the primary functions of documentation is to create and provide a central record for all collaborating providers. This record is used for clinical purposes and, increasingly, for administrative purposes (Mulholland & Healy, 2019). Third-party requirements such as the funding stipulations of managed care or regulatory bodies for accreditation are often the driving force behind documentation. Additionally, funding sources are demanding more evidence-based practice
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