ERK4499 - SECTION 12: THE CASE ACTIVITY RECORD
Section 12: The Case Activity Record
The Case Activity Record is a form that is designed to track all contact with a client performed outside of scheduled, face to face clinical sessions, as well as all collateral contacts with other parties involved in a client’s case. It is also one of the pieces of a thorough clinical record that is most likely to be overlooked and left uncompleted.
There are two important reasons why this is risky for the clinician. First, many important pieces of clinical business may be conducted outside of regularly scheduled treatment times. It is not possible to have a complete record of the client’s case unless these items are appropriately recorded.
Second, and more importantly for the sake of the clinician, there are potential risks contained in any non-direct, non-face to face contact with a client that are not present during clinical sessions. It is more difficult to assess mental status over the phone or via email, and more difficult to assess whether there is an increased risk of safety concerns. A great deal of the non-verbal information that can be discerned in a face to face session with a client is not available during other methods of communication.
The Case Activity Record serves to document the interaction between clinician and client in ways that can record the appropriateness and professionalism of the clinician’s interventions. Should any case ever lead to ethical or liability actions against the clinician, the presence of well constructed and well kept Case Activity Records is a very solid line of defense.
When is a Case Activity Record Unnecessary?
If a clinician is calling a client to schedule or reschedule a treatment session, and no important clinical information is drawn from that phone interaction, it may seem not to be absolutely necessary to record that interaction in a Case Activity Record. However, consider what would occur if that client were to reschedule an appointment, then suddenly commit suicide. If there wasn’t a record of due diligence on your part showing the change in appointments, then there may an increased liability for not maintaining a full record of contacts.
For clinicians who work with a caseload composed of less risky cases, the liability risk may be limited enough to consider not maintaining a record that complete. However, the professional standard under HIPAA guidelines is that a complete record should be maintained when electronic communications occur with clients. Each clinician will need to choose the level of risk with which they are comfortable. At the very least, whenever relevant clinical detail emerges during the course of that appointment being scheduled, it is always preferable to make note of that information in the client’s record.
It is possible to do a thorough job of tracking case actions without producing voluminous notes for each client interaction. A template for a concise Case Activity Record is shown below.
Pat R. Clinician, LCSW
Case Activity Record
Client Name: _________________________ Date/Time: _________________
Activity Type (Phone call, letter, Case conference, etc.): __________________
Activity Notes: __________________________________________________________________________________________________________________________________________________________________________________
Pat R. Clinician, LCSW Date