Recordkeeping: Say What??? Ethical Considerations in Creating a Client Record

Judy C. Roberts, MA, LMHC

About the workshop

As mental health clinicians, our clinical records serve as both medical and legal documentation of our observations of, and interactions with, the people we serve. The assumption is that those files will document the assessment, decision-making, general management, and the specific treatment(s) we provide. Traditionally they are presumed to facilitate continuity of care by the treating clinician and any successors; to verify that specific services took place, to establish “medical necessity” for third-party payers; and/or to function as evidence in the legal arena.

The fact that our records may serve in these multiple roles leaves us in an ethical bind. How does one create a functional, accurate clinical record for a client without also putting at risk the confidentiality upon which the effectiveness of that psychotherapy process is also based?

This workshop is intended to be an exploration of the complicating factors of that ethical predicament, and a presentation of a model intended to minimize its associated risks.

This workshop meets the Ethics & Law requirement.

Workshop Objectives:

Identify three functions of clinical records.
Explain the ethical bind inherent in conflicting medical and legal principles that stipulate clinical records should be complete, factual, and accurate and our ethical mandate to protect the privacy and confidentiality of our clients.
Explain the concepts of standard of practice and standard of care.
Evaluate multiple sets of record keeping standards and assess their application to their practice.
Distinguish between the possible components of a clinical record and the absolute minimal recommendations for inclusion in a clinical record.
Analyze a client’s presenting issues and construct a “statement of the problem” in contrasting to making use of DSM mental health diagnoses.
Compare four case note models and assess their usefulness.

About the presenter

Judy C. Roberts, MA, LMHC , received her Bachelor of Arts degree in Psychology from Seattle Pacific College in 1968, and a Masters of Arts in Education (counseling) from Seattle University in 1989. She began her private practice in 1989 and currently works full time in her Seattle practice seeing individual adults, couples, & older adolescents

She has served as the ethics chair for both Seattle Counselors Association and the Washington Mental Health Counselors Association since 1992, and was a founding board member of the Washington State Coalition of Mental Health Professionals and Consumers, the Pro-bono Therapy Network for Sexual Abuse Survivors, and the Puget Sound Group Psychotherapy Network.

Since 1992, Ms Roberts has been teaching professional ethics & legal issues as an adjunct faculty member at Antioch University’s graduate psychology program in Seattle, and for the past nine years has conducted many continuing education workshops and in-service trainings for mental health clinicians in WA State.

About the particulars

Location: Shoreline Center
When: January 29, 2010
Hours: 9:00am-4:30pm
Fee: $135.00 US
CEU info: 6 CEU's Cascadia Training is approved by the NASW, Washington State Chapter, to provide continuing education units to Licensed Social Workers, Mental Health Counselors and Marriage and Family Therapists. Certificates of Completion are awarded to attendees at the end of each workshop. Provider number #1975-118, and is an OSPI approved provider of in-service education. This is a "Washington State Approved Clock Hour Offering Workshop."