DOCUMENTATION inCOUNSELING RECORDS

1 THIRD EDITIONDOCUMENTATIONinCOUNSELINGRECORDSA n Overview of Ethical, Legal, and Clinical IssuesRobert W. Mitchell, ACSWAMERICAN counseling ASSOCIATION5999 Stevenson AvenueAlexandria, VA EDITIONDOCUMENTATIONinCOUNSELINGRECORDSA n Overview of Ethical, Legal, and Clinical IssuesCopyright 2007 by the american counseling association . All rightsreserved. Printed in the United States of America. Except as permittedunder the United States Copyright Act of 1976, no part of this publica-tion may be reproduced or distributed in any form or by any means, orstored in a database or retrieval system, without the written permissionof the counseling ASSOCIATION5999 Stevenson Avenue, Alexandria, VA 22304 DIRECTOR OF PUBLICATIONSC arolyn C.

2 BakerPRODUCTION MANAGERB onny E. GastonCOPY EDITORC hristine CalorussoEDITORIAL ASSISTANTC atherine A. BrumleyCover and text design by Bonny E. OF CONGRESS CATALOGING-IN-PUBLICATION DATAM itchell, Robert, 1937 Documentaltion in counseling RECORDS : an overview of ethical, legal, andclinical issues/by Robert, Mitchell. 3rd bibliographical 13: 978-1-55620-273-5 (alk. paper)ISBN 10: 1-55620-273-3 (alk. paper)1. Mental health counseling . 2. Psychiatric social work. 3. Medical RECORDS Law and legislation. I. american counseling association . II. Title.[DNLM: 1. Medical History Taking methods United States counseling United States Legislation. 3. Ethics, Professional UnitedStates Legislation.]

3 4. Medical RECORDS United States Legislation. WB 290M681d 2006] 04256 dc222006027652 DedicationThis book is for every person who ever tried to help of you makes a always have and you always the AuthorxvSpecial ThanksxixGlossaryxxiCHAPTER 1 Ethical Behavior, Values, and Professional Standards1 Ethical Conduct1 Enforceable and Aspirational Guidelines5 CHAPTER 2A Legal Perspective9 Credentials10 Charting Essentials10 Testimony and Documentation12 Missing and Incomplete Entries16 Altered Documentation16 The Record as Legal Defense17 Eight Ways to Guarantee a Lawsuit orAllegations of Unethical Conduct18 CHAPTER 3A Fiscal Perspective19 What Not to Do21 What You Must Do21 Essential Elements for the Staff Note23 Guidelines for Ethical Billing25viContentsCHAPTER 4A Coworker s Perspective27 Conclusionary Terms, Modifiers,and Abbreviations28 Problematic Staff Notes29 Possible Repercussions30 Clear.

4 Accurate Staff Notes31 CHAPTER 5A Client s Perspective35 Double Standards36 Cultural Diversity37 CHAPTER 6 Online counseling and Electronic Records41 Online counseling Services and Safeguards42 Electronic Record-Keeping Guidelines45 CHAPTER 7 Sexual Relationships and Dual Relationships53 Sexual Relationships and Ethical Conduct53 Dual Relationships in the counseling Process57 CHAPTER 8 Documenting High-Risk Cases61 Qualifiers, Violence, and Threats of Violence62 Homicidal and Suicidal Clients62 Physical and Sexual Abuse65 Criminal Behavior65 Permission for Service Form66 Additional Considerations67 Need for Specificity69 CHAPTER 9 Terminations73 The Termination Letter74 The Termination Summary75 Abandonment76 Right to Refuse Service78viiContentsFrequently Asked Questions About Documentation81 Multiple Uses of a Record81 Subpoenaed Records82 The Unofficial Chart82 Brochures and Informational Flyers83 Preprinted Forms84 Client s Use of Slang and Vulgar Language84 Faxed Client Information85 Terminations and Nonpayment85 Missing or Lost Documentation86 Filing Systems and Security87 Cosignatures, Credentials.

5 Studentsand Volunteers88 HIV/AIDs89 Disclaimer Forms91 HIPAA Basics92 Risk Exposure94 What Would You Do?: Ethical Considerations95 Scenarios for Discussion andProfessional Development95 Six Steps for the Resolution of Ethical Problems99 Concluding Thoughts100 Epilogue: You Make a Difference101 References, Suggested Readings, and Web Sites105ixPrefaceIn 2005, the american counseling association published its revisedCode of Ethics as approved by the ACA Governing Council. This is thefirst revision of the association s Code of Ethics since July 1, 1995, andit establishes critical new guidelines for professional in counseling RECORDS : An Overview of Ethical, Legal,and Clinical Issues (3rd ed.) is written to help counselors reflect on thespecific requirements of their profession in light of the new code.

6 Theprevious two editions, published in 1991 and 2001, focused prima-rily on the legal dimensions of DOCUMENTATION in the counseling pro-fessions. In response to the new code, this third edition builds on thatfocus but with an emphasis on ethical an age of legal, clinical, and fiscal accountability, record keepingand ethical conduct are important components of professional coun-seling. As counselors provide services in the 21st century, we mustaccept reality, and the reality is this: Lawsuits and allegations of unethical conduct against counse-lors continue to increase. Without adequate DOCUMENTATION andadherence to the ACA Code of Ethics a counselor s vulnerabilityis also increased. Counselors, client RECORDS , and personnel files will continueto be ordered into courtrooms because the legal system be-lieves the DOCUMENTATION contains information needed to makedecisions about child custody, involuntary hospitalization,and a wide array of other situations, including allegations ofxPrefaceunethical behavior.

7 Lack of integrity and incompetence as wellas missing, incomplete, and inadequate charts can be harmfulto the client as well as the counselor. There will be occasions when the primary counselor will be sick,on vacation, or otherwise unavailable to provide emergency ser-vice. Someone else will depend on the chart to make clinical de-cisions. Adequate RECORDS can ensure appropriate interventionand continuity of care as directed by the ACA Code of Ethics. All funding sources are demanding DOCUMENTATION that veri-fies the need for and the rendering of reimbursable activity, aswell as verification of counselor competence and accurate bill-ing procedures. Utilization reviews, peer reviews, quality assurance reviews,and committees on ethical inquiries will continue to be impor-tant parts of professional counseling .

8 An accurate, comprehen-sive record, as well as an accurate, comprehensive personnelfile, will be primary source edition emphasizes professional values as an important wayof living out an ethical commitment and reinforces the fact that in-herently held values .. guide our behaviors [and] are deeply in-grained in the counselor and developed out of personal dedication,rather than the mandatory requirement of an external organization (ACA Code of Ethics, Preamble).The volume, therefore, has a number of key purposes: To understand the multiple uses of a record, those who haveaccess to it, and its relationship to the ACA Code of Ethics To increase awareness of legal trends, the changing definitionof confidentiality, and the most frequent causes for malpracticesuits and allegations of unethical conduct To identify the record as a resource that can help counselorsface the challenges of accountability and ensure their ability tomeet human needs To recognize everyday problems associated with ineffective com-munication.

9 Including how RECORDS can be used against counse-lors in a malpractice case or in an allegation of unethical behaviorxiPreface To demonstrate how RECORDS can be used to enhance the servicerelationship, promote consumer empowerment, and providethe counselor with a defense in the event of a lawsuit or allega-tion of unethical behavior To identify the record and the ACA Code of Ethics as resourcesthat can help counselors face the challenges of accountabilityand ensure the ability to meet human needs To establish the Code of Ethics as a foundation for professionaland personal behavior To increase overall understanding of professional values andprinciples of service To demonstrate how compliance with the ACA Code can reducelegal risk exposure To provide guidelines for resolution of ethical dilemmasNone of the editions of this monograph will provide a fail-safesolution to all record-keeping problems or every ethical.

10 The books are not a substitute for competent legal the american counseling association nor the author is liablefor a reader s conduct or damages that may result from the use oftraining years of experience, countless books, articles, consulta-tions with associates, workshops I ve attended, and the National As-sociation of Social Worker s Code of Ethics aided in the development ofmy own workshops on DOCUMENTATION and ethical issues and thismonograph. Although it is impossible to credit each source of infor-mation, this publication contains a list of references and suggestedreading materials, some of which influenced the development of thiswork. When actual examples of clinical DOCUMENTATION are used, onlynames and dates have been changed to protect may not agree with everything in this monograph, and somematerial may not be applicable to your work.