Ch 6: Documentation and record keeping in clinical settings Flashcards
Two purposes of maintaining clinical documentation
- facilitates the provision of the best possible services for clients
- documents that the level of care provided to a client meets the standards of care found in the counseling profession
written records have the potential to
enhance the counseling experience
accelerate client progress
increase access to various services
protect both counselors and clients
**no universal standard exists for the style and format
clinical documentation
involves any written and/or electronic record pertaining to contact between the client and counselors and work that has occurred within the counseling relationship
EX: case notes, assessment, treatment plans, confidentiality agreements, consent for services, billing notices etc.
purpose and role of clinical documentation
track service delivery and progress
serve as memory aid
case notes
facilitate communication among treatment professionals and promote continuity of care
types of documentation found in clinical records
client ID info
informed consent docs
financial arrangements
psychosocial assessment
mental status examination results
release of info
ancillary info (test results, medical records, communication with third parties)
treatment plans
case notes
informed consent documents
include a variety of information describing what the counseling process will look like, what the client can expect from the counselor, what the client will be expected to do, how services will be arranged and how they will be paid for, and what resources the client has should the serves provided be deemed inappropriate or ineffective
consent
sought from individuals who are legally able to provide it
assent
refers to the personal agreement to engage in therapeutic activities with the counselor
with children and minors specifically
psychosocial assessment
comprehensive evaluation of a clients mental health, well being, and social functioning
common sections of a psychosocial assessment
- addresses the clients presenting problem/document the reason for seeking counseling
- looks at the clients history with the presenting concern
- family history
- history of mental health
mental status examination (MSE)
structured assessment of a client’s behavioral and cognitive functioning
used to develop baseline understanding of a clients presentation and aid in conceptualizing a potential diagnosis
subjective tool
usually done by psychiatrists/psychologists (counselor may participate)
components of MSE
appearance
level of alertness
speech
behavior
awareness of surroundings
mood
affect
thought process
thought content
memory
ability to perform calculations
judgement
higher functioning and reasoning
release of information
clients maintain legal ownership of their case files; client must consent/authorize to any release of info
treatment plans
a synopsis of a counselors work with a client
include description of clients presenting problem, potential diagnosis that may apply, goals established, and strategies/interventions planned to reach goals
three primary features of treatment plans
an overview: brief recap of why client is in services, symptoms experienced, how problem addressed/etc.
listing of long-term goals
listing of short-term goals
case notes
the session-to-session archives counselors keep about their work with clients
document what was discussed in session , the outcome of discussions, and any plans for future sessions originating from these discussions
clear, concise, and accurate
SOAP note
Subjective-objective assessment plan
STIPS note
signs and symptoms
topics of discussion
interventions
progress and plan
special issue
seven cognitive goals of STIPS
- to acquire relevant facts about the client and case
- to form diagnoses or a clinical understanding of the clients presenting problems
- to form meaningful and effective treatment plans and goals that directly relate to a clients presenting problems
- to understand within session process when working with clients and the relevant domains to track regarding a clients problems and within session goals
- to understand the counseling process across sessions with clients and how to longitudinally track a clients problems and overall progress in treatment
- to evaluate and adjust, their treatment interventions to best serve clients needs
- to use relevant criteria to evaluate the usefulness of counseling for clients at the end of treatment and to understand how their counseling interventions have led to a particular outcome in treatment for this specific client
DAP case notes
describe, assess and plan
elements of good clinical documentation
purposeful
ethical
comprehensible
must be done in timely manner/up to date
time-sensitive client info
CPS or APS reporting
case notes
conditions for releasing notes
subpoenaed by a judge (legally required to break confidentiality)(only essential information though, not everything)
good rule of thumb with ethical record keeping
if you didn’t document it, It never happened
documents that need to be saved in client records…
vary state to state and dependent on your work setting
common elements in client records
client interactions
client attendence
formal diagnosis and diagnostic impressions
meditation (current and historical)
types of services delivered
treatment plans
plans to prevent self-harm or harm to others
client billing information
**date, time, and purpose of interaction
key suicide risk assessment questions
suicidal ideation
suicidal planning
access to means
protective factors
past experiences
future expectations
health insurance portability and accountability act (HIPPA)
establishes rules for who can look at, receive, and use this personal information as well as measures health care providers must take to protect confidentiality, integrity, and security of info
two rules included in HIPPA
HIPPA privacy rule
HIPPA security use
HIPPA privacy rule
establishes national standards for how individually identifiable info is to be protected and kept private
confidentiality
refers to ensuring client information only be disclosed to authorized individuals
HIPPA security rule
sets national standards for securing personal health info (PHI) recorded electronically
4 rules to protecting PHI
- ensuring the confidentiality, integrity, and availability for all PHI personally created, received, maintained, or transmitted
- identifying and protecting against reasonable anticipated threats to the security or integrity of PHI
- protecting against reasonable anticipated, impermissible uses or disclosures
- ensuring compliance by other mental health professionals with access to the clients record and PHI
deidentification
a process used to prevent a clients identity from relating to information found in a case file
safe harbor
method to deidentifying a case file
counselor ensures that personally identifying information is expunged from the client file
18 pieces of info that needs to be removed
name
address
dates (birth, admission, etc.)
telephone numbers
vehicle identification numbers/licensce
fax numbers
device identifiers or serial numbers
email addresses
website URLS
social security
IP address
medical record numbers
biometric identifiers
health plan beneficiary numbers
photographs or videos
account numbers or client file record numbers
certificate or license numbers
code numbers
types of electronic record keeping software
yellow schedule
therapy notes
care logic enterprise
advantages of electronic record keeping
streamlined the way records are kept and maintained
free up more counselor time
quicker and more convenient access
conservation of space
disadvantages of electronic record keeping
possible data loss
risk of a breach in confidentiality
time consuming during set-up phase
making sure the program is HIPPA compliant
