ERK4499 - ETHICAL RECORD KEEPING: BEST PRACTICE FORMS AND TEMPLATES FOR MENTAL HEALTH CLINICIANS
ETHICAL RECORD KEEPING: BEST PRACTICE FORMS AND TEMPLATES FOR MENTAL HEALTH CLINICIANS
by Charles D. Safford, LCSW
Charles D. Safford, LCSW is President of yourceus.com, Inc., with guidance and input from other senior yourceus.com, Inc. course developers and from NASW GA. Mr. Safford has over 30 years of post-master’s experience as a clinician, and has over 25 years of experience as a training developer and trainer in business and clinical settings.
This course is the copyrighted property of yourceus.com and may not be copied in part or in entirety without the express written permission of yourceus.com. For information on how to secure permission to use this course or any part of this course, contact us at: firstname.lastname@example.org.
The objective of this course is to provide the mental health clinician with a comprehensive introductory overview of the essential elements of ethical clinical record keeping. When the trainee completes this course, he/she will:
- Comprehend the essential forms needed for ethical record keeping
- Know the format and components of a thorough psychosocial assessment
- Comprehend how to fill out a thorough and concise psychosocial assessment
- Understand how to compose a HIPAA compliant release of information
- Recognize the importance of maintaining Case Activity Records for all client contacts performed outside of face to face treatment sessions
- Understand how to construct best practices progress notes and superbills
- Comprehend how to compose a discharge summary
This course is primarily designed for clinicians early in their career, or for clinicians reviewing basic concepts of ethical decision making.
3 contact hours: Ethics or core hours
Section 1: Introduction
Inadequate record keeping is the third most common ethical violation made by mental health clinicians, surpassed only by role or boundary violations and incompetence in practice. One of the main purposes of this course is to provide clinicians with the knowledge base necessary to maintain clinical records that will prevent ethical problems in this area.
A second purpose of this course is to provide guidance in how to design clinical records so they are concise and efficient, and designed to work effectively within the treatment approach being applied by the clinician. Let’s be honest, paperwork is usually one of the least favorite aspects of clinical work for most people in our profession. If the forms you use are designed in the right way, then keeping good clinical records will not be so time consuming and burdensome, and this will decrease problems in maintaining the motivation to keep good records.
While all necessary information must be contained in the records, it is constructive to keep unnecessary information out. This not only protects the clinician from unnecessary paper work, done right it also protects the privacy rights of the client by keeping out of the record information that may not contribute to the clinical purposes at hand.
For this to happen, all clinical forms need to be designed well - straightforward, easy to use and to the point. They need to target the right information, and avoid gathering extraneous information. To aid the trainee in designing and/or selecting the right approach to clinical records, this course will provide best practices templates to use as a starting point. While some trainees may find the templates appropriate for their purposes with minimal changes, this course will also go into some detail about where and why the templates may require revisions to serve the purposes for which they are intended.
Each chapter in this course will consist of a study of each template, accompanied by concise information about why certain components are included in the form. Recommendations will also be made for what additions or changes might be indicated based upon the purposes and the treatment settings in which the forms will be used.
Below is a list of the forms that are typically necessary for good clinical record keeping:
- A statement of understanding/statement of services that outlines key information about treatment and the client’s rights within that treatment, including HIPAA privacy rights
- A face sheet with the client’s address and contact information, either within the assessment form or separate from the assessment form
- A completed psychosocial assessment form
- A completed treatment plan
- A completed progress note for each session
- A receipt for each session (Superbill)
- A completed case activity record for each client contact made outside treatment sessions, e.g., phone conversations, emails, etc.
- A HIPAA compliant release of information to be used whenever case information is shared with other persons
- A case closure form to be completed upon termination
Additionally, clinicians may choose to utilize psychotherapy notes, which are kept separate from the clinical records. Since these are legally not considered part of the clinical record in many or most states, we will not cover them here.
From the perspective of the clinician, the most compelling reason for keeping appropriate clinical records is to avoid ethical violations and/or lawsuits based upon negligent practice. A thorough, organized, best practice driven case record is a powerful advocate for the professionalism of a clinician should there arise any litigation or ethical complaint. However, over and above the protective function for the clinician, good records are considered essential to professional practice for a couple of important reasons related to patient care.
First, good records allow for better coordination of care. If there are multiple parties concerned with the client’s well-being, it is very useful to have all parties maintaining the information about the client in a format that is easy to share - and easy to use when shared. This aids in case supervision, in complex case planning, and in instances where clients are referred in order to access different levels of care.
With the advent of electronic medical records – and indications are that all medical providers will ultimately be required to maintain electronic medical records – it is now possible for all involved providers to have more efficient access to important information about the client’s condition, treatment and progress. In a perfect world, this allows for better and faster coordination of care, and this serves the client.
Second, good records allow for better continuity of care. Sadly, we clinicians are neither immortal nor invulnerable. The loss of a therapeutic relationship through the sudden death or disabling condition of a clinician can be a terrible hardship for a client. Mental health clinicians are ethically expected to make provisions for transition planning to minimize this harm to their clients in the event of death or disability, and the ability to have a fast and smooth transfer of medical records is important to continuity of care in these dramatic circumstances.
Less drastically, clients and clinicians both sometimes move to new cities, or one party or the other might decide that the client’s needs will be better served by having a different clinician take over responsibility for the client’s care. Good medical records minimize the harm done to clients by this disruption in care by allowing the new provider to take over care with a detailed picture of what has already been done in treatment.
Third, records that are designed properly can help structure the clinician’s work in ways that improve both effectiveness and efficiency. Well designed forms can help the clinician remember to gather and keep track of the most necessary information for the clinical work – no more and no less. This supports not leaving anything important out, and not putting into the clinical record anything that exceeds what is helpful, protecting the client’s privacy in the process.
In short, while it is a burden to maintain good medical records, there are sensible reasons and functional purposes behind this expectation. What will next be examined is how to keep those burdens to a minimum while still maintaining excellent records.