_____________________________ Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
of the documentation. Practitioners should document with the expectation that a much wider audience than expected may read what is written. The content of excellent clinical documentation provides insight into client needs, justifies and chronicles the course of intervention, and demonstrates progress and outcomes. Mitchell (2007) takes the viewpoint of charting for the reader. He proposes basic principles to create a useful record for col- leagues and clients. • Language should be clear and specific, avoiding irrelevant statements or excess verbiage. • Whenever possible, the client’s own words should be used. Write what is heard. • Write what could be comfortably shared with the client. • Write records logically. Ensure that charting has some relevance to the presenting problem or the guiding treatment plan. If charted information is not pertinent to either, it should not be included. “Usefulness requires specificity, and vague writing might be construed as indicating incompetence” (p. 31). • Avoid modifiers (such as soon or sometime) that are abstract or could leave room for doubt. Ultimately, according to Mitchell (2007), records should be understandable and accountable. Although HIPAA does not specify what is required in a medical record, according to Groshong and Philips (2015), the follow- ing must be included to meet behavioral health guidelines. • Billing information and payment records • Formal evaluations • Collateral contacts, including release of information (ROI) for all • Records from other providers with ROI • Counseling session dates, with start and stop times • Modalities and frequency of treatment • Medications • Diagnoses • Functional status (activities of daily living [ADL], ability to work, interpersonal capacity) • Medical/physical problems • Community contacts, including phone calls, emails, or texts
• Disclosure forms and informed consents signed by licensed professional and client • Presenting problem(s) or purpose of visit • Referrals to and results of formal consults • Progress notes sufficient to support responsible clinical practice for the type of orientation/therapy used All digital medical records should be backed up regularly and kept in encrypted format, with frequent changes in passwords. Although there can be both medical record and psychotherapy notes, information cannot be put in psychotherapy notes to avoid putting it in the medical record (Groshong & Phillips 2015). OVERALL CHART ORGANIZATION Chart organization and content may differ across settings. Organizations can require specific and structured information, whereas private practitioners have more flexibility as to order and organization. Bodek (2010) provides a framework for organizing a patient record for healthcare settings and advises that a file folder exclusive to each patient be maintained. The folder would consist of: • Demographic information, including insurance and referral information • Intake information, including assessment, evaluation, and initial history • Service or treatment plan • Progress notes • Referrals or consultations made, collateral reports, and test results • Correspondence from other practitioners • Correspondence with patient or collaterals • Billing records • Informed consents/authorizations or other privacy- related information releases Consents and authorizations do expire, so records should con- tain original and updated forms so that the history of consent to services, communications, and such is evident (Hoffman & Herveg, 2021). In addition, it is recommended that a Health Insurance Privacy and Accountability Act (HIPAA) compli- ance folder for each patient be maintained separately from the patient’s clinical record and psychotherapy notes. Another organizing framework, offered by Sidell (2015), for a thorough clinical record includes the following five categories.
• Treatment plan and goals • Symptoms and prognosis • Progress in each session
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