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Good Documentation Brings Peace of Mind​​​​

Good Documentation Brings Peace of Mind

One of the most frequently discussed risk management topics among healthcare professionals is documentation. It's become a risk management cliché, but nevertheless it's true: if you didn't document it, you didn't do it or it didn’t happen. If the client or even a family member ever sues you, the client’s case notes will most likely be called into evidence. Failure to keep good records of a client’s sessions can be detrimental to you in a lawsuit.

Counseling Basics and Documentation

As a counselor, you are already aware that a session should include several points.

  • Purpose: Clearly define the purpose of the counseling.

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  • Flexibility: Fit the counseling style to the character of each client and to the relationship desired.

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  • Respect: View the client as a unique, complex individual, with a distinct set of values, beliefs and attitudes.

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  • Communication: Establish open, two-way communication with the client using spoken language, nonverbal actions, gestures and body language. Effective counselors listen more than they speak.

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  • Support: Encourage the client through actions while guiding them through their problems.


Your documentation should correspond with what the session includes. If you fail to write that you did a thorough assessment of a client, or you fail to fully explain your counseling techniques and approach for this client, for instance, it could become your word against theirs in a lawsuit. Documenting the client's status before, during and after treatment is imperative. You need to include how receptive he or she was to the counseling you provided, and your response to any concerns the client had. If you keep taped recordings of the session, make sure they are transcribed into the client’s case notes with your accompanying notes of the session.

One Virginia certified psychologist, Dr. Mates, quickly discovered the importance of detailed documentation when a case was brought against him for failure to refer, resulting in a client’s death. At the time, the decedent resided at a community rehabilitation center where Mates was employed. He was suffering from schizophrenia. Part of his treatment included a regimen of Clozaril, a medication that can cause agranulocytosis or the decrease of white blood cells. A week before the decedent’s death, he complained of flu-like symptoms to Mates. Mates recommended that the decedent visit his primary physician for treatment of the flu-like symptoms. However, it was discovered that Mates’ notes had no mention of the recommendation. Mates’ lawyers contended that the decedent died of an overdose of Clozaril and not from the infection. The jury found that Mates failed to refer the decedent to his primary physician and came back with a verdict of $225,000 against Mates.1

If the client’s case notes included notes stating the recommendation to seek further treatment, Mates would have had more validity in his defense. It’s a case of “not documented, not done.” The lack of notes in the client’s case notes could not prove that Mates did what he said he did.

Guide to Documentation

To ensure thorough notes, several experts recommend that counselors remember to document the following:

Observations at the beginning of each session. You won't know how your client is responding to treatment unless you know where he or she started, and how it compares with the end of the last session. Include restating the purpose of the counseling, the client’s current mood and attitude, and their actions, gestures and body language. These facts and observations will assist in the development of a plan of action for each session.

Subject matter of each session.Outline the components of the counseling session. Using the information obtained from past sessions, identify main points of discussion, list possible comments or questions to help you keep the counseling session client-centered and help the client progress through its stages. Although you never know what a client will say or do during counseling, a written outline helps organize the session and enhances the chance of positive results. Document the client’s respective responses.

Communication with your client. In many cases, you may want to approach the session with a client by openly explaining the plan of action for treatment. By documenting this discussion, you will obtain a reference to the agreed upon plan and the client’s accomplishments, improvements, personal preferences or problems. In turn, your client should be encouraged to share their expectations of their counseling sessions. A complete documented record of counseling aids in making recommendations for the client and can assist in establishing the approach of upcoming sessions.

Results of treatment. Record your client's response to what you do and say. Document what is spoken or avoided, tone of voice, and any changes to the initial mood, attitude, actions, gestures and body language. This is particularly important with patients who indicate they are at risk of harming themselves or others, including such things as having cognitive distortions, beginning a cycle of devaluation.

For example, in California, a woman was under the care of a therapist for a psychological stress condition. She alleged that she was sexually molested and that the defendant failed to monitor her treatment in an appropriate manner. The defendant denied that the sexual molestation occurred and maintained that the plaintiff suffered from borderline personality disorder that existed long before he treated her. It was further argued that the disorder predisposed her to chronic fluctuations of idealization and devaluation of her caregivers, and that poor reality testing, inherent instability associated with this severe disorder and depression contributed to the fabrication of the claims. All of this was repeatedly documented in the plaintiff’s case notes. It included the change of mood toward the therapist and actual quoted statements of the plaintiff during sessions. The courts found in favor of the defense.2

Follow-up plan. Indicate what you plan to do about the client's response to therapy. If he or she exhibits a change for the worse -- or no progress at all -- indicate in your notes whether you made or plan to make the appropriate adjustments in the plan of action. Establish any follow-up measures necessary to support the successful implementation of the plan of action. These may include providing the client with resources, and consulting with the referring health professional or following through on your referrals. Schedule any future ​meetings before ending a session.

Additional thoughts or observations. If a counselor has any other professional thoughts or opinions related to the client and the session, then it should be documented. If any actions are taken or need to be taken after the client exits the meeting place, make detailed notes in the client’s file, following up with the results of the action. Make sure you take the time to do it before your next appointment so that it is still fresh in your memory. Waiting can cause you to forget to note something, opening yourself up to risk if you ever get sued.

Special note: If you do place notes or amend anything in a client’s file at a later date, make sure you initial it, date it and include the time of day, indicating the addition is a late entry. This will ensure that you are not suspected of falsifying the records after the fact. If you are ever suspected of falsifying records, it could cause you to lose the malpractice case filed against you, and it may even trigger an investigation by your licensing board. You could also be brought up on criminal charges. 

Many healthcare professionals feel that taking too much time to document the details takes away from their client care, but this is in fact part of client care. Good documentation will assist you whenever you need to refer to the client’s history. When you work with so many clients, you can’t expect to remember everything about each one. Also, when you are away at a seminar or on vacation and have someone filling in for you, you can be sure that counselor is taking good care of your clients because they can refer to your notes in the client’s case notes. Good, thorough documentation will also help you if you are ever named in a lawsuit. Not only can it help you defend yourself in a malpractice lawsuit; it can keep you out of court in the first place.

If you would like more information about keeping good case notes that are legally sound, Please click here to review the ACA publication Documentation in Counseling Records, Second Edition by Robert Mitchell. For information on ACA publications, call 800-422-2648 extension 222.

References

  1. Medical Malpractice Verdicts, Settlements & Experts; Vol.16, No.4, April 2000.


  2. Medical Malpractice Verdicts, Settlements & Experts; Vol.19, No.2, February 2003. Other information is reprinted in part from the NSO and HPSO Risk Advisor.

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