Informed consent Flashcards
Informed consent
The ongoing process of informing clients about their therapy for the purpose of helping them make autonomous decisions pertaining to it. The aim is for clients to become involved, educated, and willing participants in their therapy
informed consent DOCUMENT
Providing clients with a written statement pertaining to many aspects of their therapy that is generally discussed and signed by both therapist and client
(Boundaries)
Termination process
An effective termination process is critical in securing trust in the overall therapy process and minimizing the return of symptoms or feelings of exploitation. Termination is a key phase of every client’s treatment, and therapists should help clients plan for it, prepare for it, and process it
Confidentiality
Confidentiality is a right granted to all clients of mental health counseling services. From the onset of the counseling relationship, mental health counselors inform clients of these rights including legal limitations and exceptions. (I.A.2.a.)
Record keeping
Clinical perspective
From a clinical perspective, record keeping provides a history that a therapist can use in reviewing the course of treatment.
Record keeping
Ethical perspective
Records can assist practitioners in providing quality care to their clients.
Record keeping
Legal perspective
State or federal law may require keeping a record, and many practitioners believe that accurate and detailed clinical records can provide an excellent defense against certain malpractice claims
Record keeping
Risk management
risk management perspective, keeping adequate records is the standard of care
Management Strategy
Accurate, relevant, and timely documentation is useful as a risk management strategy
Maintaining clinical notes serves a dual purpose
Provide the best service possible for clients, and
provide evidence of a level of care commensurate with the standards of the profession.
Progress notes
A means of documenting aspects of a client’s treatment. They are kept in a client’s clinical record. These notes may be used to document significant issues or concerns related to a client’s treatment
Accurate, relevant, and timely documentation is useful as a risk management strategy
Behavioral in nature and address what people say and do.
information on
* diagnosis,
* functional status,
* symptoms,
* treatment plan,
* prognosis, and
* client progress.
Process notes
Also known as psychotherapy notes, they deal with client reactions such as transference and the therapist’s subjective impressions of a client. Process notes are not meant to be readily or easily shared with others
Process notes are not meant to be readily or easily shared with others. They are intended for the use of the practitioners who created them.
a form of self-consultation and a way to organize ideas to bring up in supervision.
exclude from process notes
a form of self-consultation and a way to organize ideas to bring up in supervision.
Keeping records
Ethical, clinical, and legal requirement
What to enter into record keeping APA
Identifying data
Fees and billing information
Documentation of informed consent
Documentation of waivers of confidentiality
Presenting complaint and diagnosis
Plan for services
Client reactions to professional interventions
Current risk factors pertaining to danger to self or others
Plans for future interventions
Assessment or summary information
Consultations with or referrals to other professionals
Relevant cultural and sociopolitical factors
