Part 2: Clinical Supervision Ethics:
Clinical Records

Both the supervisor and the supervisee are responsible both ethically and professionally to build and keep up the clinical records.To sound redundant, the records record and, in some way copy or reflect the supervisee's professional work. Often the records are the only way for you, the supervisee, and necessary others to know what the supervisee did and why. Consequently, the supervisee will want to keep high-quality records to reflect high-quality work. If any of it is called into question in the future, accurate records will make explanations and accountability easier.

[Question #19. Keeping up clinical records is the responsibility of:]
a) The supervisor
b) The supervisee
c) The agency's office staff
d) The supervisor and the supervisee

Some keys to good records are legibility and accuracy, made as soon as possible after therapy or another contact is completed. Logical organization that is replicated in every record is also essential. If there is ever a conflict between agency policies and procedure of the applicable code of ethics, you'll need to address the conflict in the manner delineated in the code of ethics. You must clarify the nature of the conflict, state your commitment both to the agency and the code of ethics, and--as much as possible--resolve the conflict in a way that follows the code of ethics (American Psychological Association, 2007).

Some states have a list of requirements for what is included in the mental health record of any child or young adult that is in foster care. California has no such requirement.

As a matter of course, the client's record is often quite full before much therapy has taken place. Under the guidelines of your agency, you'll need to make some decisions about the record content. You should consider the:

* Nature of the service(s) given to the client
* Source of recorded information
* Intended use of the records
* Professional obligations of each profession contributing to or otherwise using the file

Some agencies have a mandated record format, a list of specific information to be collected and recorded, and a given time frame within which to create the records. Your supervisees will try to include only information pertinent to the purposes of the service given. They--and you--will need to be cognizant of the possible impact on the client of language used in the record (e.g., representing symptoms as a disease, using derogatory terms).

Ethical and legal requirements must be met and risks considered. Information given in broad or vague terms may not be enough for continuity of care or building a satisfactory defense against malpractice, criminal, or state licensing board complaints. On the other hand, some clients may want you to keep a minimal record to give them maximum privacy and protection.

As you struggle with some of these issues, there are several specifics that may offer some guidance (American Psychological Association, 2007):

The Client's Request. For whatever reasons, a client may ask that only limited records of treatment be kept. Sometimes the client may even make that the deal breaker as to whether or not she will accept treatment. You and the supervisee may decide that treatment cannot be given under this circumstance and that serving such a client is not in the best interest of either the client or the supervisee.

Emergency or Disaster Relief Settings. An emergency or disaster relief situation may not allow or require substantial records. A disaster relief agency may only want short identifying information, the date and quick summary of services rendered, and the name of the provider. Or opportunity to keep detailed records may be lacking, especially in an immediate or short-term crisis. In some settings, such as disaster relief following a hurricane, there is not likely to be intervention beyond what may occur on-site; the brevity and small number of services provided may not allow detailed records to be constructed even after the crisis.

Alteration of Destruction of Records. Many regulations, statutes and rules of evidence forbid alteration or removal of information once a record has been made. In a litigation, adding or removing information from a record that has been subpoenaed could create liability for your supervisee and yourself. It's best that anything added later be documented as: "When reviewing the file on (date), I realized I had forgotten to mention…."

Legal/Regulatory: Some regulations and statutes order that certain information must, or must NOT be included in the record. For example, a statute may forbid you referring the results of an HIV test or giving information about chemical dependency treatment. You and your supervisee will need to follow all such mandates.

Agency/Setting: The agency for which you work may have policies and procedures about the level of detail permitted in the record. This will be discussed further in the section on Record Keeping in Organizational Settings.

Third-Party Contracts: You'll need to think about whether the amount of detail in a record meets the agreements in contracts with the agency and third-party payers. A number of third-party payers' contracts call for specific information to be included in a record. Not meeting the terms of the contract could precipitate non-payment, required reimbursement of funds that were already received, or legal actions.

Three kinds of information may be included in the record of psychological services (American Psychological Association, 2007):

1. Basic information

• Identifying data (e.g., name, client id number)
• Contact information (e.g., phone number, address, next of kin)
• Fees and billing information
• Where appropriate, guardianship or conservatorship status
• Documentation of informed consent or assent for treatment
• Documentation of waivers of con?dentiality and authorization or consent for release of information
• Documentation of any mandated disclosure of con?dential information (e.g., report of child abuse, release secondary to a court order)
• Presenting complaint, diagnosis, or basis for request for services
• Plan for services, updated as appropriate (e.g., treatment plan, supervision plan, intervention schedule, community interventions, consultation contracts)
• Health and developmental history

2. For each contact of substance with a client

• Date of service and duration of session
• Types of services (e.g., consultation, assessment, treatment, training)
• Nature of professional intervention or contact (e.g., treatment modalities, referral, letters, e-mail, phone contacts)
• Formal or informal assessment of client status

3. Other information, dependent upon the circumstances

• Client responses or reactions to professional interventions
• Current risk factors in relation to dangerousness to self or others
• Other treatment modalities employed, such as medication or biofeedback treatment
• Emergency interventions (e.g., specially scheduled sessions, hospitalizations)
• Plans for future interventions
• Information describing the qualitative aspects of the professional-client interaction
• Prognosis
• Assessment or summary data (e.g., psychological testing, structured interviews, behavioral ratings, client behavior logs)
• Consultations with or referrals to other professionals
• Case-related telephone, mail, and e-mail contacts
• Relevant cultural and sociopolitical factors

When discussing the presenting complaint, diagnosis, or basis for request for services the therapist will attempt to get a routine, but sound medical and psychiatric assessment. The client may or may not be willing and/or able to give this history. If not, then the therapist must try to get information from family and caregivers. It's possible that much will have already been given to the agency before the client ever appears, such as previous psychiatric assessments and treatments, and the extent the client conformed to past treatment. Review this information as soon as possible.

The therapist may not request information without the consent of the client. However, if that information is give without a request from the therapist, patient confidentiality is not violated (Routine Psychiatric Assessment, 2009).

The interview should first investigate--through the use of open-ended questions--why the client has come. Then exploration for broad view of the client's personal history is pursued. The therapist will review significant past and present life events and the client's responses to them. [Question 21. The mental status exam (MSE) is to determine the client's cognitive functions, including:]
a) Orientation to person, time, place, and space
b) Concentration
c) Judgment
d) Short- and long-term memory
e) All of the above

Also to be noted in this initial assessment are:

• Appearance
• Attitude
• Behavior
• Mood and affect
• Speech
• Thought content
• Thought process
• Perceptions
• Cognition
• Insight

Related to the psychiatric history are social history, family health history, responses to normal variations of life, developmental history, daily conduct, and the potential of the client harming himself or someone other person. The Merck Manual sums up the most basic things to explore in each of these areas:

Areas to Cover in the Initial Psychiatric Assessment
Area	Some Elements
Psychiatric history	Known diagnoses Previous treatments, including drugs and hospitalizations
Medical history	Known disorders Current drugs and treatments
Social history	Education level Marital history, including quality and stability of marriage Employment history, including stability and effectiveness at work Legal history, including arrests and incarcerations Living arrangements (e.g., alone, with family, in group home or shelter, on street) Pattern of social life (e.g., quality and frequency of interaction with friends and family)
Family health history	Known diagnoses, including mental disorders
Response to the usual vicissitudes of life	Divorce, job loss, death of friends and family, illness, other failures, setbacks, and losses
Developmental history	Family composition and atmosphere during childhood Behavior during schooling Handling of different family and social roles Sexual adaptation and experiences
Daily conduct	Use or abuse of alcohol, drugs, and tobacco Behavior while driving
Potential for harm to self or others	Suicidal thoughts and plans Intent to harm others

(Routine Psychiatric Assessment, 2009)

The most important psychological diagnostic tools are the history and the mental status examination (MSE). These tools have been standardized, but they're still primarily subjective measure. They begin the instant the client comes into the office. The therapist pays close attention to the client's presentation--personal appearance, interactions with the office staff and others in the area, and the patient is accompanied by someone (to help determine if the client has social support). Important information about the client can be obtained through these observations that might not be disclosed through an interview or a one-on-one conversation (Brannon and Bienenfeld, 2011).

From this information the therapist will determine a working diagnosis, another permanent part of the record. Depending on agency guidelines, this will probably be based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV). (The fifth edition is/was due in May, 2013.) As a rule, the initial diagnosis remains attached to the client, although other diagnoses may be added if necessary. It's therefore important to be thorough in determining the diagnosis, for it will not only be used as a therapeutic guideline, but also as a determination for payment.

Required Client Forms

There are a few forms that are required in most mental health records. In some cases, the client only needs to be notified verbally or in writing only. Often these notifications are part of the intake paperwork. This is good, because it will not be easily overlooked. However, often the client will not carefully read what he's signing, so it's recommended that each of the following consents and acknowledgments be given both in writing and verbally. A copy of the signed, written form should be included in the record; in this way there will never be a doubt as to whether the client received the information or not.

In these instances the client is either giving consent for something, such as treatment, or is acknowledging that she has received information, such as privacy rules.

Informed Consent

Informed consent, which must be in the client file, requires anyone who receives any service or intervention to be adequately aware of what will be happening, what the potential risks are, as well as alternative approaches so that the person can make an informed and intelligent decision to accept and participate in that service. This form is essential for protecting the supervisee and/or supervisor from legal concerns. As supervisor, you must inform the supervisee about what the process of supervision includes, including evaluation criteria and feedback, as well as other supervision expectations. You must be certain that the supervisee has informed the client regarding counseling and supervision parameters, such as live observation, and audio- or videotaping.


[Question #23. Which of the following is/are true of informed consent:]
a) It is a single event.
b) It is a process that changes over time.
c) Subsequent consent to treatment discussion should all be documented.
d) b and c

[Question #24. One of the informed consent forms a client must sign is consent to be treated by a trainee. This form need NOT include which of the following about the supervisee:]
a) Professional discipline (i.e., social work, counseling, psychology, nursing)
b) Specialty (i.e., counseling, clinical, school)
d) Treatment philosophy or orientation
e) When the supervisee received his degree

There are a couple of potential ways for a client to pay for mental health services:

1. Personal Health Insurance: Insurance policies vary widely in the amount and type of mental health care they will cover. The client will need to know about their particular policy. There are a number of questions they should ask their insurance company. Before they make an appointment they should ask:

• Will the policy pay for mental health services in the city and state the agency is located in?
• Which mental health services are covered by my policy?
• Can I see the provider of my choice or must I choose from a "preferred list of providers"?
What happens if I want to see someone not on that list?
• Is there an annual limit on the number of counseling sessions covered?
• Does my plan exclude certain diagnoses or pre-existing conditions?

If the answers to those questions are satisfactory, then the client should ask the company representative:

• Will the company pay for the services I need? If so, will they pay the entire cost?
  • If not, what costs are not covered?
  • Is there a co-pay?
  • Is there a deductable?
  • What is the amount of my plan's "usual, customary, and reasonable (UCR)" coverage?
  • Does fee of the therapist at the agency I want to go to ($___) meet the UCR coverage?
• Do I need a pre-certification, prior authorization, or referral from my primary care provider?

2. Sliding Scale Fee. Community mental health services (and sometimes other services) often offer a sliding scale option. Clients who must pay from their own funds because they have no insurance or because their insurance does not cover the treatment they need may be able to work out a sliding fee scale from your agency. The agency will then charge the client according to what he can afford based on the financial condition and household income.
No matter which form of payment is agreed upon, the exact agreement must be in writing and signed. A signed copy of this agreement is part of the client's record.

[Question #25. Under HIPAA, a client does NOT have which of the following rights:]
a) The right to request restriction on the uses and disclosures of protected health information (PHI)
b) The right to request amendments of her designated record set(DRS)
c) The right to request confidential communications
d) The right to request an accounting of disclosures
e) None of the above

In certain times and locations, there has been or is a stigma against receiving treatment for mental health. The confidentiality laws are in place to protect individuals from discrimination coming from this stigma. HIPAA protects not only disclosures made during treatment, but also the fact that the individual is in mental health treatment. This can also be a protection for family members and the therapist from potential danger should a violent individual who has intimidated the client learn that the individual is receiving support and from whom she's receiving it.

Confidentiality is generally counted on as a foundation of the therapist-client relationship. As a rule, therapy is most successful when the client trusts the therapist. The confidentiality laws help to preserve this trust. The therapist must never confirm or deny that an individual is or has been a client, unless there is a legal exception to the confidentiality. In addition, every detail of written and verbal communication in the course of assessment, treatment, testing, or any other communications are also protected as private information.

[Question #26. HIPAA makes some exceptions to confidentiality that include:]
a) Threat of harm to self or others
b) Any criminal activity disclosed
c) Involuntary commitment
d) a and c

[Question #27. Potential responses to a subpoena for client information never include:]
a) Stating that you can neither deny nor confirm that any specific individual is a client and cannot release information from any client record without a court order or client consent.
b) Negotiate with the issuer of the subpoena
c) Ignore the subpoena
d) Modify the subpoena

Court-Order Disclosures: If the court orders a therapist to disclose client information when the client will not authorize a release, the therapist may cooperate with the court. Therapists are not expected to bear penalties for contempt of court; it's also assumed that the court has decided that society's needs in such a case override the values of confidentiality to either the client or society.

Reasonable Suspicion of Abuse of Neglect: People in certain professions are legally mandated to report suspected or alleged abuse or neglect of children, elders, or dependent adults. Therapists are in that group. In this case, children are defined as people under age 18; elders are defined as people age 65 or older. The definition of dependent adults is people between 18 and 64 whose mental or physical limitations restrict their ability to care for themselves.

• Reporting: Mandated reported does not require that there is conclusive proof of neglect or abuse; rather, when functioning in her professional capacity, there is "reasonable suspicion" of abuse. The report is to be made to either the police or to the Department of Social Services. It must also be given in writing--by mail, fax, or electronically--within 36 hours for children or within two working days for adults.

Contacting authorities such as a child welfare agency does not necessarily constitute reporting; the therapist may contact them to help determine if the situation fits the mandatory reporting law. The California Welfare and Institutions Code only requires therapists to disclose information they happen upon in the course of profession activity, and only when there is a present danger. It may be considered present danger if an adult client reports past sexual abuse by a person currently in a household with children--the children may be at risk of abuse.

The therapist is not required to report a claim of neglect or abuse if the person reporting it has a mental illness or dementia, there is no corroborating information or evidence, and the therapist reasonably believes that the abuse didn't occur.

• CANRA: In California, the law that pertains to abuse and neglect of children is largely in The California Child Abuse and Neglect Reporting ACT (CANRS). The purpose of the Act is "to protect children from abuse and neglect." Included in its intention is protection of the child's welfare during investigation: "In any investigation of suspected child abuse or neglect, all persons participating in the investigation of the case shall consider the needs of the child victim and shall do whatever is necessary to prevent psychological harm to the child victim."

(Source: Your MFT Ethics, n.d.a)

The HIPAA laws protect the client's privacy. However, the client can overrule many of those laws by signing a release of information, a copy of which should remain in the client's record. [Question #28. HIPAA allows free use of client information for which of the following:]
a) Use by the therapist that originated treatment notes for further treatment.
b) Use or disclosure by the therapists for training programs under supervision to practice and improve their abilities in individual, family, joint, or group counseling.
c) Use or disclosure by the therapist as defense in legal or other proceedings brought by the clients.
d) All of the above

Without a signed release of information, the therapist cannot even acknowledge whether or not an individual is or has been in therapy, let alone any particulars about treatment. The release of information is generally quite specific as to the time during which information may be released to which person or organization.

Without a signed release of information, the therapist cannot even acknowledge whether or not an individual is or has been in therapy, let alone any particulars about treatment. The release of information is generally quite specific as to the time during which information may be released to which person or organization.

[Question 29: HIPAA states that a release of information form must NOT:]
a) Advise patient of his right to receive a copy of the authorization
b) Be separate from all other documents in the client's file
c) State specific uses and limitations of the use of the information by the persons authorized to receive it
d) None of the above

Because, without a release of information, you can only advise a referring organization that you cannot release requested information, it's important that you or your agency be sure that the staff of referring organization are aware that this can happen. Employee assistance professionals can aid in such situations in several ways. They can help employers establish company policies and train staff regarding issues such as confidentiality in compulsory referrals. Employee assistance professionals who are also clinicians may also counsel with employers on interpersonal and mental health issues to improve management staff's ability to improve morale, interact with employees, and decrease legal liability.

There are several aspects of what a client's current status can refer to. Those useful to the client's record might be summed up as the status of clinical outcome and quality status (Linkins, Brya, and Johnson, 2011). All of them should be reviewed periodically and a copy of that review placed in the client's file.

Clinical Outcome Status

Clinical outcome began with a mental status examination in the first clinical session or two, which resulted in a treatment plan, both of which become part of the client's record. The client's current clinical outcome status should be reviewed in terms of the client's status within the treatment plan and the current mental status.

Current Status within the Treatment Plan

The treatment plan should be reviewed often, with a focus on the current status of the client in relation not only to the therapy plan, but to any other services and supports that the client is receiving (Prior Authorization Utilization Review, 2007). Report the progress that has been made towards any of the treatment plan goals. Mention whatever has motivated the progress or impeded it. Although all of these are likely in the therapy session notes, it's helpful to group them together in this review. If necessary, revise the treatment plan to fit the current status.

Current Mental Status

The Mental Status Examination is for the purpose of determining how the client is functioning mentally, emotionally and behaviorally at the moment of the exam. As has been mentioned, much of this is accomplished through the keen observation of the therapist. There is actually a wide variation between agencies in terms of data that is actually measured and the strategies and instruments used to collect the data.

Some of the most commonly used mental status assessment measures, besides criteria in the DSM-IV, are the Duke Health Profile, the Global Assessment Scale (GAS) and the similar Global Assessment of Functioning Scale (GAF). Some agencies also use assessments of depression.

Duke Health Profile (DUKE): The DUKE has been popular among health and mental health researchers since it came out in 1998. Its popularity continues to this day, probably because it's a simple to take and score self-report instrument that has a record quite good validity.

There are only 17 items for the client to answer as "Yes, describes me exactly," "Somewhat describes me," or "No, doesn't describe me at all." Of the questions, seven are general attitude questions, two refer to how the client believes he can do two physical tasks, and the rest refer to how the client functioned during the past week.

The assessment covers six health measures (physical health, mental health, social health, general health, and perceived health), a "stand-alone" self-esteem score, and four dysfunction measures (depression, anxiety/depression, pain, and disability). The assessment and scoring forms are freely available online (Duke University Medical Center, 2005).

Global Assessment of Functioning Scale (GAF): The GAF is a revision of the Global Assessment Scale (GAS), a procedure for measuring the overall functioning capability of the client during a specified period of time. Both scales are a single-item rating scale to be filled out by the clinician. There is also a children's form of the GAF.

The GAF is used by the DSM in its "multiaxial" assessment system. The system has five axes for assessment (I: Symptoms that need treatment; II: Personality and developmental disorders; III: Medical or neurological conditions that may influence a psychiatric problem; IV: Recent psychosocial stressors; V: Client's level of function). The GAF is the Axis V component (Mezzich, J. E., 2002).

The GAF reflects the therapist's judgment of the client's ability to function in daily life. It looks at psychological, social, occupational functioning.

The scale ranges from 1 (theoretically very ill and unable to function at all in daily life) to 100 (theoretically very healthy and totally able to function in every area of daily life). The client's 5-axes diagnosis might read as:


Axis I: Adjustment Disorder with Depressed Mood, Alcohol Abuse, Cannabis Abuse
Axis II: No Axis II diagnosis
Axis III: Hyperthyroidism
Axis IV: Divorce on (date)
Axis V: GAF = 56 (on admission), GAF = 65 (on discharge)

[Question #30. The DSM has a 5-axes assessment system that includes:]
a)Symptoms that need treatment
b) Recent psychosocial stressors
c) Score from the Duke Health Profile
d) a and b

Quality Status

Quality refers more to the treatment than to the client. Every agency is pressed for quality improvement in their services by government agencies, payment sources, and clients themselves. New assessment tools frequently appear. The Center for Quality Assessment and Improvement in Mental Health (CQAIMH) has an online "finder" of mental health treatment quality assessment measures (CQAIMH, n.d.). If you find one that fits the kind of treatment you're offering a client, you can include a periodic update as to the continuing improvement of the treatment quality you're giving.

A mental health treatment plan is a written document that outlines the expectations for therapy. Depending on requirements of payment providers and the agency, the therapist's preferences and the severity of the presenting problem, the plan may be quite formalized or may simply be composed of loose handwritten notes. If an electronic record system is used by the agency, this may dictate the treatment plan format.

Nowadays, formalized treatment plans are required more frequently than in the past. However, no matter how lose or how formalized the treatment plan is, it's always subject to change during the progression of therapy.

The plan is based on needs identified during the initial assessment and diagnostic process. The process used to choose the level of care needed should be documented. Depending on the problem(s), treatment plans may include family information (Council of Juvenile Correctional Administrators, 2007).

[Question #31. A formal treatment plan includes:]
a) Presenting Problem
b) Goals of Therapy
c) Time Estimate
d) Interventions and methods
e) All of the above

Often achieved via informally discussion the situation, the client should always be included in developing the treatment plan and this should be recorded in the record. Some therapists give the client a written copy of the treatment plan; others believe this can cause an unnatural feeling to the therapeutic relationship. However, a copy of the plan should always be given to a client who requests it (Fritscher, 2011).

In addition to the treatment plan itself, often kept in the record is a full deblockedive summary that combines biopsychosocial information and a summary of key clinical issues; it functions as a connection between the treatment plan and the assessment. The narrative summary pinpoints diagnostic signs for any existing mental health problems, and includes both the reasons for the assessed level of care and any substitution for that level of care (Utah Division of Substance Abuse and Mental Health, 2009).

Progress

In many ways, psychotherapy is to a certain degree an unstructured process. This causes many clients who are experiencing guided self-discovery and behavioral change to ask themselves if therapy is helping. Repeated taking of a self-report questionnaire to track progress gives both client and therapists a chance to see what is improving from the client's perspective--the most important perspective.
Self-report data given via a formal assessment has often been used to:

• Add to the accuracy of clinical assessments
• Give a basis for treatment planning
• Provide an objective way to track treatment progress
• Use clinically proven guidelines to warn therapists to get stubborn cases back on track
• Aid in preventing hospitalizations through warning guidance
• Give referral sources some outcome-based information to link patients to therapists with a proven track record of giving outstanding treatment to clients with similar needs

An example of such a self-report assessment is the Patient Health Questionnaire (PHQ-9), an assessment for depression that is available online (PHQ-9, (1999). Like other most successful assessments of this sort, it's short (ten questions) with easy-to-answer questions (check the level that best suits: Not at all, Several days, More than half the days, Nearly every day). The validity of the test over time is also good.

These sorts of assessments, grouped under "behavior health outcome management" (BOHM), can be used every session to track progress. With real-time scoring and report generation (which can be done in a very few moments) both clinicians and clients receive excellent evaluation about the course of treatment and whether or not adjustments to the treatment plan should be made (Lambert, 2005).

Although it has not always been the case, some of the newer, more advanced assessments can reliably document improvement on a single domain more than 50% of the time and, with a multi-dimensional analysis, more than 90% of the time (Kraus, Seligman, and Jordan, 2005). With payers and purchasers alike looking for documentation of client improvement, you may want to research and evaluate applicable assessments.

According to the Core Battery Conference (CBC), a core assessment battery should address three distinct areas:

• Quality of life, or general distress
• Symptom clusters (e.g., anxiety, depression, mania, psychosis, etc.)
• Functional domains (e.g., work and social functioning)

Kraus, Seligman, and Jordan (2005) identified only one battery that met all of the criteria defined by CBC with a short questionnaire, the Treatment Outcome Package (TOP Toolkit). The free package includes assessments for children, adolescents, adults, and substance abuse, as well as a couple of assessments of client satisfaction and a wealth of other information (Behavioral Health Laboratories, 2011).

As clients proceed through therapy, progress and treatment plans are reviewed and assessed, and needed changes in the treatment plan are made to reflect the progress or lack thereof. In addition to the continual assessment of progress, the process includes:

• Comparing progress to criteria for continued service or discharge
• Determination of when the client can be treated at a different level of care or treatment approach based on resolution of problems and/or priorities

Treatment often ends when a frustrated client leaves prematurely. Following the procedures outlined above will hopefully reduce the number of times that happens.

Problems in Not Meeting Treatment Goals

Assessments aside, there will be clients who just can't seem to meet treatment goals. This seems especially true in cases involving substance abuse. The treatment plan should include reports of lack of response to treatment or meeting therapy goals, or if the client is disruptive in treatment. As you would expect, the treatment plan needs to be appropriately revised (Office of Alcoholism and Substance Abuse Services, 2010).

Significant Actions Taken and Outcome

The main point in again mentioning "significant actions taken and outcome" is to emphasize their importance in the psychotherapy notes. Sometimes it's helpful to gather them from the individual session notes and group them into a narrative. This can add perspective that will give good guidance as to where you should go next.

Whenever you document a therapy session or other communication with or about a client, always keep in mind the possibility that this documentation could very well sink or save you in an instance of litigation. Some tips to follow in making this documentation the most helpful it can be may sound mundane and unrelated, but with thought you'll likely see the sense of it.

Competent documentation (Lifson and Simon, 1998) should be unambiguous and cognizant of grammar essentials--a misplaced modifier is not your friend:

"The client is a 21-year-old admitted on 7-5-11 to ___ with a history of psychotic behavior, evaluated at the ___ Center and seen by a social worker there with a chemically induced psychosis."

If you didn't make progress notes, but instead kept "process" notes to remind you of your own associations and counter-transference reactions, as well as your theories about treatment, these may not be truly be private, but may be "discoverable" in the event of litigation involving your client or between your client and you.

[Question #32. You discover you left important information out of a progress note. You can:]
a) Add the information to the note
b) Ignore it and hope it won't be a problem
c) Make a new note, date it "today," and state that you realize you forgot to include. . . .

If you're bent on self-destruction as a therapist, one of the easiest ways to do this is to keep no notes or poor, incomplete notes. If you noticed something in therapy, you need to respond to it and then document that response.

Although preventing liability for your sake is important, the leading rationale for good documentation is that it contributes to, facilitates and enables, and is essential to client care. Documenting or charting weekly, biweekly, or monthly does you, your clients, and even your colleagues an immeasurable disservice.

These tips can be summarized in three basic rules that will minimize risk to both you and your clients (Lifson and Simon, 1998):
1. Write smarter, not longer.
2. If you didn't write it down, it didn't happen.
3. Never, ever change a record.

The North Dakota Department of Health (n.d.) gives several lists of what to do when "Charting with a Jury in Mind." Some of these are repetitious, which only emphasizes their importance:

• Basic Charting Rules:
  • What is documented, what is not documented, and how it is documented is vital
  • Sins of Omission: Don’t omit the obvious--e.g., failure to make an entry
  • Shadow of a doubt: Don’t allow inaccuracies
  • Tampering with the evidence: Don’t obliterate an entry
  • Relying on recall – Don’t wait to chart
  • Just the facts, Ma'am
  • Don’t chart conclusions
  • Record only what you see and hear
  • Describe, don't label, events and behavior
  • Don’t get personal
  • Neatness counts
  • Chronology of events: Give each entry its own page
  • Failure to communicate – What you don’t say may hurt the patient
  • Juries can't read minds – Document intermediate steps
  • The appearance of error: Being at fault versus appearing to be at fault--the outcome may be the same.
• In notes regarding the continuity of care, be sure to note:
  • Transfer of Health Information to hospital or specialty
  • Transfer of Health Information to prisons or jails
  • Discharge summary
• Daily do's and don'ts for charting:
  • Check the name on the patient’s chart
  • Use ink or typewriter, not pencil
  • Read the notes on the client before either providing care or charting
  • Use concise phases
  • Make entries in order of consecutive shifts and days. Write the complete date and time of each entry.
  • Sign each entry with your title
  • Indicate client non-compliance
  • Be sure you know the meaning of all the terms you use
  • Use direct patient quotes when appropriate
  • Be accurate, factual, timely, and complete
  • Use accepted medical abbreviations
  • Don’t backdate, tamper with, or add to notes already written
  • Don’t write general statements, make them specific: e.g., client is adapting to divorce; instead tell in what ways the client is adapting
  • Don’t chart procedures in advance
  • Wait until end of shift to chart; either keep notes during sessions or write them immediately after the session
  • Chart for someone else
  • Throw away notes with errors on them, mark the error and include the sheet
  • Erase, obliterate, or write in margins
  • Skip lines between entries
  • Leave a space before your signature
  • Make derogatory remarks about the client
DO: DON'T:

Client Fails to Follow Clinical Directives

It may be that your client--or that of your supervisee--will not progress, or will progress so slowly as to make no difference unless they follow the clinical directives, which will necessarily be part of the treatment plan. But the therapist is frustrated because a particular client continually fails to follow the clinical directives.

Three questions may be asked in such situations (Relaxed Therapist, 2006):
1. Why should your clients do anything you say?
2. Why should your client do what you’re saying now?
3. Why wouldn’t clients follow your suggestions?

The answer to "Why should your clients do anything you say?" may be found in the relationship between you and your client and within yourself. How you see yourself and your role in the therapeutic relationship will decide to what extent you expect the client to follow your advice. If you see yourself--and perhaps more importantly, if your client sees you--as the "bus driver" to take the him to his destination, you'll be the one frustrated if the client keeps challenging the route you take because he wants you to be only the travel agent.

Why should your client do what you're saying now? Because you've studied your heart out and continue to do so in order to know what direction you clients need to go in, you may have come to believe that there is only one right way to recovery. Or you may have a number of ways the client can go towards recovery, but the client believes there is likely only one way and it doesn't fit any of the ways you're suggesting.

You may be the one with the therapy experience, but your client is the one with the "being me" experience. If you client says a certain way won't work for him, you'll save time, energy, and frustration if you don't try to convince him why it will work for him.

Instead, find out why she thinks it won't work for her, why she or her situation are different from everyone else. There may be no different but, then again, there may be. You won't know without asking; you need to ask the client what she thinks WILL work for her. She's more likely to follow her own advice, and perhaps you can lend a helpful hand in the process--which is the way therapy works in the first place.

[Question #33. If a client won't follow your suggestions, some of the reasons may be:]
a) They don't understand it.
b) They tried it but got a negative reaction.
c) They tried it but couldn't do it on one attempt.
d) They don't believe it will work.
e) All of the above

Any of those feelings is likely a deal breaker. All of this is reinforcement for the need for the client to be a major part of making the treatment plan.


[Question 34. Which of the following statements are true regarding whether or not a client must follow the therapist's directives:]
a) The client never has to follow your directives.
b) The client should always follow your directives.
c) The client must follow your directives when their problem has legal consequences.

Telephone Conversations with Client and Others

It may be difficult to get into the habit of writing therapy notes about telephone conversations with a client or with others, such as social workers, about them. However, it's just as important--sometimes more important--to document these calls as it is to document a therapy session. If you have a call with a social worker and that person keeps a record and you don’t, there could easily be a time when your memory does not match their notes and it could lead to problems. It's especially important to document phone calls that are related to issues with legal consequences.

An example of a dilemma that could arise from not documenting a telephone call: E-Mails, Phone Messages, and Texts


[Question #35. Modern digital technologies have added new considerations in the field of mental health. Which of the following are true when using e-mail, mobile phone messages, and text messages?]
a) Lack of privacy is of no concern.
b) There is no potential problem of security.
c) "Caution" is the by-word when using these methods.

Should the actual voice-mail messages, texts, and e-mails be included in the client's clinical record? A basic and simplistic answer is that at the very least, notes on the content of these messages if they have clinical or other significance should be in the record. Messages that it may be important to archive include those during a crisis or other high-pressure situations, or if therapists are flooded with messages from clients in ways that may be or become stalking, harassment, or threatening.

Phone messages from clients are not a new phenomenon. Ever since the advent of the answering machine the potential for clients leaving a message for their therapist has been a reality. There are several way to handle these messages, in addition to the aforementioned written notes about the content of the message.

• The message may be recorded and transferred to a CD that will be part of the client's file.
• If you have a digital answering system, it can give you the message as an MP3 or similar file. The file can be transferred as an e-mail attachment on some mail systems, which can then be stored on the agency's computers. If the file can't be transferred by your e-mail system, you can copy it to the same CD already mentioned.
• There are systems available, some free (such as Google Voice), that will save the voice-mails as recordings and e-mail them to you, along with a tranblocked (however inaccurate) of the message. You can then save it in a Web-based e-mail program or download it to the agency's computer system. The rub here is the issue of privacy. If you use a means such as this, you'll need to have your clients sign an Informed Consent form that explains risks involve in using this kind of communication because of the storage method.

E-mail is becoming a common and acceptable way to for therapists and clients to communicate. It can be a time saver for needed rescheduling of appointments, eliminating the game of phone tag, busy phone lines, being put on hold, and numerous other annoying problems of phone calls.

However, all is not gold when it comes to e-mail communication with clients (Zur, 2010a). What about the suicidal client that sends an e-mail you don't see for 18 hours? Or the client who, by the nature and length of their e-mail, extends the time of their session by half an hour? Or who wants a "short" answer right away to a therapy questions? Or--the list could be quite long.

Also, e-mails are fundamentally vulnerable because they can be accessed by unauthorized people fairly easily, compromising the confidentiality and privacy of the communications. Encrypting your e-mails requires the complexity of public and private encryption keys and teaching clients to use them. Or you can use an Informed Consent form that delineates privacy risks so clients can choose whether or not to use e-mails. This consent form would be included with others that clients are required to sign (Zur, 2010b).

The consent form may also include charges that may be incurred when the e-mails and their responses essentially extend therapy session, and any other guidelines you have for the use of e-mail with clients. All of this information must also be stated verbally in a therapy session--probably more than once. Zur (2010a) offers some excellent guidelines for using e-mail with your clients:

• Clarify to yourself your thoughts and feelings regarding e-mail communication with clients. What are your preferences, your limits, etc.?
• If you're considering using e-mails as an adjunct to therapy, make sure you become HIPAA compliant.
• Discuss the issue of e-mail communications with clients, when relevant, in the first session. Learn from them about their expectations and clarify your expectations and boundaries. Continue the dialogue as clinically and ethically necessary throughout the course of therapy.
• Make sure that your office policies include a section on the use of e-mails.
• If you're conducting tele-health, follow state laws, relevant codes of ethics, and have a separate informed consent, which is required in some states, such as California.
• Make sure your computer has a password, virus protection, firewall, and backup system.
• Make sure that each e-mail includes an electronic signature that covers issues such as confidentiality and security.

E-mails should be printed out and included in the client's file.

Texting is one of the newer methods of communication between clients and therapists. Some agencies may not allow therapists to give out their cell phone numbers, preferring that clients that call after hours be transferred to an answering service that will transfer the call to the therapist on-call. And many therapists may not want to offer 24/7/365 availability to their clients. Regardless, it's almost inevitable that there will be a time in the near future when, because of the health market becoming more and more consumer-driven, many administrative and simple communications between clients and therapists will be done via cell phones and texting.

In fact, on-call therapists for an agency might have a company cell phone for use during their on-call time. This may be a problem for those older therapists who can't or won't learn to text.

As with other electronic communications, issues of security, confidentiality, and privacy are an inherent part of texting. A signed Informed Consent form, like the ones mentioned above, or a list of Office Policies that the client receives on intake should be used.

At the very least text messages should be summarized, and the summary placed in the client's file. However, you can also have an actual record of the text itself to place in the file (possibly with a "translation" into "real English" for the sake of others who must read the file and who are not savvy to all of the texting abbreviations). Here are several ways to keep that record (Zur, 2010b):

1. A service such as Google Voice can record and save phone text messages. Therapists would set it up and give that number to clients; they will then have a record of all texts.
2. The service Missing Sync connects therapists' phones to their computers and backs up (archives) the text messages.
3. You can use an online for-fee service, such as Treasure My Text, that stores the text messages online by allowing for simple uploads of messages via text.
4. Some cell phones, such as iPhones, allow therapists to take screen-shots of their text messages and then send them to their e-mail address as an attachment.

All of these methods involve online services and will therefore have potential--sometimes inherent--problems of security, confidentiality, and privacy. Some programs may have security measure in force, but you'll want to check them out before you use them, and always employ Informed Consent forms.

HIPAA confidentiality rules are always to be considered. If you communicate with your clients through e-mail and if you store clinical records digitally, you must be sure that your computer has impeccable password, firewall, virus protection, logs, and backup systems, encryption if necessary, and other computer safety measures (Zur, 2010b).

You also need to be aware that HIPAA has some special rules for "a health care provider that conducts certain transactions in electronic form (called here a 'covered health care provider')" (HIPAA, 2005):

"In electronic form means: using electronic media, electronic storage media including memory devices in computers (hard drives) and any removable/transportable digital memory medium, such as magnetic tape or disk, optical disk, or digital memory card; or transmission media used to exchange information already in electronic storage media. Transmission media include, for example, the internet (wide-open), extranet (using internet technology to link a business with information accessible only to collaborating parties), leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media, because the information being exchanged did not exist in electronic form before the transmission."

If you're a covered entity, you must comply with HIPAA's Privacy Rule (HIPAA, 2003) and Security Rule (HIPAA, n.d.), which are different from the HIPAA rules that are discussed elsewhere in this course.

Consultations

Documentation about consultations with a social worker or another professional within your organization is just as important as documenting any other transaction or communication with or about the client. The only reason this topic has been given a section of its own is to emphasize that it's just as important as any other kind of documentation.

Gifts from Clients and Reasons Accepted


[Question #36. Sometimes you or your supervisee must decide whether or not it is ethical to accept a gift from the supervisee/client. Factors to be considered in your decision include:]
a) The nature of the gift
b) The cost of the gift
c) The therapeutic/supervisory relationship between the one giving the gift and the one receiving it
d) The transference or other issues that led to giving the gift
e) All of the above

The therapist must address the issue in each individual case. The answers to a couple of questions can help find the answer:

1. Will the acceptance or refusal of the gift adversely affect the well-being and health of the client?
2. What is the meaning behind the gift?

The setting and the nature of the therapeutic relationship influence the decision as well. It may be permissible to accept certain gifts from a client that comes in once a year for a session, but accepting the same gift from a client that is currently having weekly therapy sessions may not be permissible. The primary criterion by which to judge if the action is ethical is the client's best interest (Lyckhom, 1998).

All Information Related to Suicidal, Homicidal or Abuse Concerns

Even though it may be another time burden to suitably document a suicide risk assessment, it's something your supervisee sometimes must do, and you must see the he does it. It's best done immediately after a clinical evaluation of the client (Ministry of Children and Family Development, n.d.).

Although it's tempting to use a form with "Yes/No" check boxes (e.g., Is the client suicidal?) or a subjective rating scale from 1-5, it's better to do a thorough risk assessment and a step-by-step narrative of the clinical judgment and planning that followed.

Clear documentation that records the risk assessment, estimation of risk, approach to safety planning, treatment goals, and clinical consultation is important for a number of reasons:

1. To make relevant information for other professionals should they need it
2. To serve as a quality assurance checklist
3. To indicate that good clinical care often rests on good clinical documentation
4. To protect against malpractice
5. If documentation is poor, the risk of litigation is high even if the clinical care was good

Documentation of suicide risk in an outpatient setting should include:

• Initial interview
• Emergence or re-emergence of suicide ideation, plans, or attempts
• Significant changes in the client's condition

[Question #37. When you need to assess suicide risk in a young person, you should:]
a) Ask the client directly
b) Estimate the risk level based on a thorough assessment
c) Ask parents, caregivers and other sources of collateral information for their perspectives
d) Re-evaluate the risk status periodically
e) All of the above


[Question #38. What is the single, most helpful thing an agency can give its therapists and supervisors to help in dealing with suicidal or homicidal clients?]
a) A good armamentarium of assessment tests
b) Regular CEU classes on the topic
c) Clear, written policy of management of these clients
d) Support and encouragement

There are basically two kinds of situations for which documentation of continuity of care is required:

• Evidence of continuity of care from other providers
• Continuity of care upon transition to other providers

If consultations take place, a copy of the consultation should be present in the record as evidence of continuity of care maintained between the two providers (VA Premier Health Plan, 2007).

The non-profit National Committee for Quality Assurance is working with a number of federal and state agencies, as well as private businesses to improve healthcare quality. One of the areas in which they're striving to build this quality is in the area of continuity and coordination of care. The organization has a seal that is widely known as a symbol of quality. Medical organizations that wish to include the seal into their marketing and advertising must pass a rigorous review and report on their performance annually.

One of the requirements in this review is that there is continuity and coordination between medical and mental health care (National Committee for Quality Assurance, 2011). The two questions they must positively answer (and prove) are:

• Does the organization monitor the coordination of general medical care and behavioral health care?
• Does the organization collaborate with its behavioral health specialists in collecting and analyzing data and implementing actions to improve the coordination of behavioral health with general medical care?

Ways some of the medical providers (Excellus BlueCross BlueShield Connection, 2009) live up to these continuity and coordination of care issues are by:

• Evaluating and assisting as to when exchanges of information between providers are necessary
• Determining the content of the exchange
• Ensuring that after the intake assessment, follow-up is timely (no later than the third visit), and appropriate
• Ensuring that the patient’s written consent has been obtained

Records are kept as evidence of continuity of care between the primary care physician and the behavioral health provider. Essential collaboration includes sharing or acquiring a summary of recent behavioral health clinical outpatient or inpatient care in the previous 12 months and/or relevant treatment information via written or telephone communication that is included or documented in the treatment record. Records also include written communications and/or documentation of telephone conversations that include an assessment, working DSM-IV diagnosis and a clinical plan of care.

A standard electronic document, the Continuity of Care Document (CCD) is being developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Health Information Management and Systems Society (HIMSS), and the American Academy of Family Physicians (AAFP). Its purpose is to promote and improve continuity of patient care, to reduce medical errors, and to make certain of at least a minimum standard of the transportability of health information when a patient or client is transferred or referred to, or is otherwise seen by another provider (Continuity of Care Record, 2003).

Confidentiality of Records

Questions sometimes come up in regards to access to records because of differences between state and federal laws. The Health Insurance Portability and Accountability Act of 1966 (HIPAA) laws are the primary federal laws in these differences. In California there are three main sources of law that may be involved:

• Confidentiality of Medical Information Act (CMIA) Civil Code (Sections 56, et seq.)
• Information Practices Act of 1977 (IPA) Civil Code (Sections 1798, et seq.)
• Patient Access to Health Records Act (PAHRA) at Health and Safety Code (Sections 123100 – 123149.5)

Patient Access to Records
[Question #39. True or False: HIPAA allows psychotherapy notes to be withheld from the clients under certain circumstances.]

If this access to mental health records is denied, the client must be informed of the denial. Also, written records of both the request and the reasons for denial must be put in the client's file (California Health and Safety Code, 2010). If the individual affected directly by that disputes the decision, California's IPA law requires a state agency to re-examine its determination that that particular information is exempt from access (California Department of Health Care Services, 2007).

When there are differences between state and federal laws, the state laws preempt the federal laws. This statement is based on the Federal Register (Standards for Privacy….) statement, "…A state law may also not be preempted because it comes within section 1178(a)(2)(B), section 1178(b), or section 1178(c); in this situation, a contrary federal law would give way."

Inspection by Parents of Child’s Mental Health Records


[Question #40. Health providers may refuse to give parents access to their child's health and mental health records. Which of the following is NOT an acceptable requirement?]
a) The child is age 16 or older
b) The provider believes this access would have a negative effect on his professional relationship with the child
c) The provider believes this access would damage the child's physical safety
d) The provider believes this access would damage the child's psychological well-being

Discretion to Not Inform Parents without a Minor's Consent: The California Family Code (2010) requires the health care provider to involve a parent or guardian in a minor's treatment unless the provider determines that this involvement would not be appropriate. This decision and any attempts to contact parents must be documented in the minor's record. There will be some necessary sharing of certain confidential information if parents are involved in treatment. Nonetheless, participation in treatment does not mean parents necessarily have a right to access the confidential records. To whatever extent possible, providers should try to regard the minor's right to confidentiality while still involving parents in treatment (California Family Code, 2010).

Discretion to Inform Providers without Authorization: Records kept in connection with treatment or prevention of drug abuse that is regulated, conducted, or assisted--whether directly or indirectly--by the California Department of Alcohol and Drug Programs cannot be shared with providers who are not working for the same treatment or prevention program except in an emergency (California Health and Safety Code, 2010). Health care providers working for programs that are not state assisted may share information for treatment or referral services with other providers. However, without written client authorization, they may not share psychotherapy notes (California Civil Code Section 56-56.07, 2010 and National Center for Youth Law, 2010).

Disclosure of Record Keeping Procedures

Disclosure of record keeping procedures is potentially a part of informed consent (American Psychological Association, 2007). As you recall, an Informed Consent document is a statement of what will be happening in therapy, its risks, benefits, and alternatives, and signed by the client before beginning therapy and giving consent for therapy. A notice of HIPAA privacy laws that has been signed as having been explained to the client is also a part of the informed consent process. Also discussed were informed consent forms for using e-mail, texting and other electronic communications between client and therapist.

Sometimes, the client might want to know how the records will be maintained, and this may include disclosure of record keeping procedures. This may be particularly important if the procedures will probably affect confidentiality or if the client articulates expectations about record keeping that are different from required procedures.

[Question #41. Disclosure of record keeping procedures is potentially a part of informed consent. What information might be needed for a client to decide whether or not to sign the consent form?]
a) Client records may become part of an electronic file that can be accessed by a wide range of institutional staff.
b) When mental health client records are released with appropriate permission to do so, from that point it's possible that they might be distributed further without the therapist's or client's knowledge or consent.
c) Records released in a context of litigation may be placed in the public domain and be accessible to anyone.
d) In some educational settings, federal, state, and institutional regulations require record keeping procedures that could enlarge the range of people who have access to the records of a school psychologist.
e) All of the above

Maintenance of Records

To be clinically useful and legally safe, clinical records must be kept up-to-date and be well organized.

Records are only useful if efficient retrieval is possible. Records that are organized logically and updated systematically, and that are thorough and accurate accomplish this. The therapist and supervisor can more easily monitor ongoing care and interventions. If the client's care needs to be transferred elsewhere, for whatever reason, this sort of records allow for continuity and coordination of care.

Organizational Methods

There are a variety of methods for organizing the records to aid in storage and retrieval. Logical and consistent methods will generally be most useful. For example, a logical file labeling system will assist in recovering records (American Psychological Association, 2007).

Dividing the files into several sections may be helpful:

• Psychotherapy notes
• Client information that is intended to be shared with others
• Material generated by the client, client's family members, prior treatment providers, or other third parties
  • Behavioral ratings or logs
  • Diaries
  • Journals
  • Letters
  • Pictures
  • Videos
  • Greeting cards

Because psychological test data may require especially careful consideration before being released, and therefore may best be clustered within the file to make that perusal easier. A specific, often overlooked, area of concern is the re-release of data from previous therapist's records as a part of the record that should be released. Should the therapist decided not to release that information, having that in a separate part of the file will make it easier to carry out that decision.

When asked for legitimate release of information for which a release form has been signed, the therapist must still consider several items:

• HIPAA regulations regarding psychotherapy notes
• Breadth of records requested
• Client's wishes
• Situational demands

For example, the therapist has received a court order of "any and all records" that were used when the therapist formed certain opinions. It would likely be necessary to re-release some third-party information that is in the record. However, the therapist can give advance notification to the client, allowing enough time for an objection to be raised before responding to such requests for records.

Psychotherapy Notes

For privacy reasons, HIPAA has given its own definition of psychotherapy notes. A discussion of progress notes follows the outline of the applicable HIPAA definition and rules.

Some items that have traditionally been included as parts of the psychotherapy notes have been defined by HIPAA as something separate. HIPAA's definition of psychotherapy notes is:

[Question #42. According to the HIPAA definition of psychotherapy notes. Items NOT mentioned that these notes don't include are:]
a) Modalities and frequencies of treatment furnished
b) Medication preblockedion and monitoring
c) Summaries of the diagnosis, symptoms, prognosis, and progress
d) The complete treatment plan

HIPAA states that psychotherapy notes are to be kept separate from the rest of the record. Only the provider who took the notes (or others within the provider's agency) can access them, unless there is a HIPAA complaint authorization from the client (American Psychological Association, 2007).

Providers are exempt from forwarding or otherwise sharing psychotherapy notes with other entities without client authorization, except for legally defined exceptions. Physically integrating information included in the above list into the psychotherapy notes does not automatically mutate it into protected information.

If a provider has integrated information excluded from the definition of psychotherapy notes with a psychotherapy note (e.g., results of clinical tests, symptoms), the provider is responsible for extracting information that is required to reinforce the reasonableness and necessity of a Medicare claim, or other legal request for information (Provider Inquiry Assistance, 2005).

The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) is responsible for enforcing the privacy protections and access rights for consumers. The HIPAA privacy rule does not require or allow any new government access to medical information, with one exception: the rule does give OCR the authority to investigate complaints and to otherwise ensure that covered entities comply with the rule. In order to ensure covered entities protect patients' privacy as required, the rule provides that health plans, hospitals, and other covered entities cooperate with the Department's efforts to investigate complaints or otherwise ensure compliance (U.S. Department of Health and Human Services, 2001).

Psychotherapy notes are sometimes called progress notes. Some of the information that HIPAA excludes in its definition of psychotherapy notes are summaries. However, the specifics that formed the basis for the summaries are included in the psychotherapy, or progress notes. The progress notes:

• Include date and duration of the session
  • Document cancellations and no shows
  • Document gaps in service (incarcerations, hospitalizations, vacations, etc.)
• Include type of intervention
• Refer back to objectives stated in the treatment plan
• Record what was said or done in the session
• In a form that will be most helpful to the therapist, record:
  • Hypotheses
  • Personal reactions
  • Doubts, expectations
  • Possible interpretations
  • Supervisory recommendations
• Financial arrangements for payment and associated information

Face-to-Face Therapy
Anyone acquainted with the field of therapy is familiar with face-to face therapy. The client and therapist meet and have a session. This most often takes place in the therapist's office, but can also occur in hospitals, jails, or similar settings. But because of the experience of the years for this kind of therapy, record keeping and process notes easily fall into the deblockedions above. Electronic Therapy Before the advent of the Internet, face-to-face therapy was the only type of therapy, except for crisis telephone services. In recent years, therapists have taken advantage of the Internet and the telephone to offer almost the whole gamut of therapeutic services. This kind of therapy not only has a number of names (e.g., TeleMental Health, Telehealth, E-Therapy, E-Counseling), it's also provided by a variety of means:

• Avatars
• Chats
• E-Mail
• Skype
• Telephone
• Texts
• Video-conferencing

A variety of client populations have eagerly sought these sorts of therapy, including those who:

• Don't want to be seen going into a therapist's office
• In rural areas that are some distance from a therapist's office
• Are incarcerated
• Are homebound
• Work better with frequent, intermittent conversation, rather than a block of time each week
• Are more comfortable with the anonymity of text formats than face-to-face formats

However, clinical, ethical, and legal facets of electronic therapy are in many respects still under construction. There is an ongoing discussion, for example, as to whether most of these formats conform to HIPAA privacy and confidentiality laws. Whole courses are available to train the "electronic therapist" in the ethical and legal considerations (including conducting therapy across state lines, HIPAA, reimbursement, etc.), as well as the delivery of electronic therapy with its practice, logistic, and technologic aspects (Zur, Ofur, 2011d).

Nonetheless, if your supervisees provide any kind of electronic therapy, records must be kept. The rules and regulations and other discussions above all apply.

Security

In light of confidentiality and privacy for every individual, there must be suitable protection against unauthorized access to or loss of the records. As a safeguard against electronic and physical breaches of confidential information, there needs to be limited access to the records. New challenges to preservation of security have appeared because of advances in technology. However, there must be a plan in place to protect the records (American Psychological Association, 2007).

Two basics to consider are:

1. The medium on which the records are stored
   

   Paper records must be kept in safe location where they may be protected not only from unauthorized access, but also from damage or destruction (water, mold, fire, insects). Condensed records, or a full copy of them, may be kept in separate locations to better protect them from disasters--natural or unnatural.

   Electronic records may need protection from different kinds of damage--mechanical insult or electric fields; power outages or surges; attacks from viruses, worms, and other destructive programs. A plan for archiving files may include off-site storage of data or file and system backups.

2. Access to the records

   Access to paper records may be controlled by storing files in locked cabinets or other such containers that are housed in locked offices or storage rooms.

   Access to electronic records may be controlled via security procedures such as firewalls, passwords, authentication, and data encryption.

[Question #43. Client records that are on paper, must be protected from:]
a) Unauthorized access
b) Water damage
c) Fire
d) Insect damage
e) All of the above

[Question #44. Client records that are in electronic form must be protected from:]
a) Unauthorized access
b) Power outages or surges
c) Insects
d) a and b

Retention of Records

There are numerous potential circumstances that might require a release of client records after termination of client contact (e.g., legal proceedings, requests from treatment providers or the clients themselves). They may also be needed at some time for the social worker or therapist to show the nature, quality, and rationale for services provided. It's also a possibility that the records might be requested to give light in resolving a legal dispute and administering justice when the nature of the treatment provided or the psychological condition of the client at the time of services would be needed (American Psychological Association, 2007).

This gives rise to the question of just how long you should keep the records. Perhaps the most practical answer is, "As long as necessary for the future care of the client, and as long as the record may be used in the defense of the therapist" (Cole, 2001). The APA states that, unless there is an overriding requirement, it would be good to keep records for seven years after the last service delivery date for adults or until three years after a minor reaches the age of majority, whichever is later. However, they also state that you may want to keep them longer. These suggestions are the law in California; each state has its own laws.

In deciding whether to keep the records for a longer period of time, you would want to weigh the potential benefits associated with keeping the records versus risks associated with potential privacy loss or having information that is outdated/obsolete. Possibilities that you may want to consider when making the decision to continue to keep or to eradicate files include:

• Earlier records of symptoms of a mental disorder might be helpful for the client in later diagnosis and treatment.
• Or, the client might be better served if later diagnosis and treatment was not influenced by something more than seven years in the past.
• The client might have engaged in behavior as a minor that, if disclosed later (when, for example, he decided to run for Congress) could prove demeaning or embarrassing.
• Keeping the record over an extra-long time might be expensive and/or logistically challenging.

One other item to consider: The client has the right to amend his medical records as long as you have the record (Pritts, 2005).

Preserving the Context of Records

[Question #45. Preservation of the context of client records includes:]
a) The location in which the records are kept
b) A given time frame during which services were delivered
c) A specific situational context during which services were delivered
d) b and c

Electronic Records

Issues pertinent to electronic records have already been discussed. But, because of the extreme importance and uniqueness of electronic records, it will be tied together here with some addition information.

Aspects of electronic record keeping that need to be kept in mind are:

• Limitations to their confidentiality
• Methods of keeping the records secure
• Measures needed to maintain the integrity of the records
• Unique challenges of disposing of the records

In many cases, those in the social work and mental health fields will be subject to the HIPAA Privacy Rules and Security Standards. This requires a detailed analysis of the risks associated with your electronic records. It would likely be helpful to conduct that risk analysis even if you're not technically subject to the HIPAA rule.

These HIPPA requirements are also a means to help you to closely examine certain office practices:

• Assuring that you handle personal health information in a manner that will protect clients' privacy
• Defining acceptable deidentification if needed for research or other purpose
• Clearly defining required elements in a release of information authorization

[Question #46. Precautionary actions that can be taken to protect unintentional electronic disclosure of confidential information include:]
a) Use passwords and/or encryption to protect confidential materials
b) Use case identification numbers, not clients' Social Security numbers to identify records
c) Get training in special issues when using electronic media or consult with a specialist when necessary
d) Become aware of special issues raised when using electronic methods and media
e) All of the above


Record Keeping in Organizational Settings

Organizational settings, often present unique record keeping challenges. Record keeping requirements for organizations may be substantially different from requirements in other settings. You may run into conflicts between the organizations' practices and establish professional guidelines, legal and regulatory requirements, or ethical standards. In addition, ownership of and responsibility for a record is not always clearly defined. A number of service providers may access and contribute to the record, potentially affecting the degree to which you may execute control of the record and its confidentiality.

This may be summarized as potential:

1. Conflicts between organizational and other requirements
2. Ownership of the records
3. Access to the records

You, your colleagues, and your agency's management may need to consult with one another to define record keeping procedures that serve the needs of different disciplines, while at the same time meeting acceptable record keeping guidelines and requirements. In this consultation, you'll need to review local, state, and federal regulations and laws that pertain to the organization. If there is a conflict between an ethics code and the organization's policies, you'll need to clarify the nature of the conflict, make your (and others involved) ethical commitments known, and resolve the conflict in a way that is compatible with those ethical commitments.

The nature of your legal relationship with the organization may dictate record keeping practices. The physical record of your services may be owned by the organization and you may not take it with you. However, if the relationship is one of consultation, you may be the one who owns and is responsible for the record. It will be helpful to clarify these issues when you begin your relationship with an organization, minimizing the possibility of misunderstandings.

If a team of people from different disciplines is involved in service delivery, there may need to be wider access to records than usual. Because others (e.g., nurses, physicians, paraprofessionals, etc.) may have access to and may make entries into the client's record, you may have much less direct control over it. This is another call for you to help in developing and refining organizational record keeping policies.

Note that because multidisciplinary records may not have the highest level of confidentiality, you and your supervisees will want to record only information that matches organizational requirements and that is necessary to correctly picture the service provided. Other information may then be kept in a separate and confidential file (American Psychological Association, 2007).

Multiple Client Records

Record keeping issues may be more complex when you provide services to multiple clients, such as in a group therapy session. If the records include information about more than one specific client, legitimate disclosure of information regarding that client may put another client's confidentiality in jeopardy.

It's the responsibility of you and your supervisees to keep records in a fashion that assists authorized disclosures but at the same time protects privacy of other clients. When you provide services to several people who have a relationship (e.g., spouses or parents and children), you must define at the beginning:

1. Which individuals are clients
2. Your relationship with each person, including your role and the likely uses of the services you give or the information obtained.

If it looks like you may be asked to play potentially conflicting roles (e.g., family therapist and then witness for one part in divorce proceedings), you must take judicious steps to appropriately clarify, modify, or withdraw from a specific role or roles.

In a group therapy setting, you must describe at the beginning each party's role and responsibility, and the limits of confidentiality. If you're asked to provide services to someone who is already receiving similar services elsewhere, you must consider carefully any treatment issues and potential welfare of the client(s). Discuss these issues with the client (or the client's guardian or other legal representative) to diminish risks of conflict and confusion. Also, when appropriate, consult with the other service providers, always being cautious and sensitive to therapeutic issues (American Psychological Association, 2010).

Other precautionary steps you can take include:

• In the informed consent form, include whether information is kept jointly or separately and who can authorize its release.
• In couples, family or group therapy, clarify the identified clients, then create and maintain completely separate records for all identified clients.
• If the family itself is the identified client, you may need to keep a single record, dependent upon practical concerns, ethical guidelines, and third-party reporting requirements.

To successfully "pull all of this off," you'll need to be familiar with regulatory and legal requirements concerning the release of a record that contains information about more than one client (American Psychological Association, 2007).

Financial Records

Financial records are considered by HIPAA to be part of the protected psychotherapy notes; at least they're not on the list of unprotected information. As a rule, a fee agreement or policy will be part of the record, and is the foundation for documenting reimbursement for services. Precise financial records aid payers to evaluate the nature of the payment obligation, and also aid in knowing which services have been billed and paid. Records that are up-to-date can forewarn both the provider and the client of accruing balances that, if not addressed, could adversely affect the professional relationship.

Financial records include (American Psychological Association, 2007), as appropriate:

• Type and duration of the service given
• Client's name
• Fees paid for the service
• Agreements concerning fees
  • Fee agreements or policies identify the amount to be charged for service and the terms of any payment agreement. It will identify how missed appointments will be handles, acknowledge third-part payer preauthorization requirements, copayment agreements, payment schedule, interest that an unpaid balance will accumulate, suspension of confidentiality when collection procedures must be used, and methods that may be used to solve financial disputes.
• Barter agreements
  • An accurate recording of bartering agreements and transactions ensures that the record clearly shows how the provider was compensated. Reporting the source, nature, and date of each barter transaction gives clear indication when needed about the exchange of goods for services. Because the provider could potentially have more power in negotiating a bartering agreement, painstaking documentation protects both parties. The documentation may include the provider's basis for initially concluding that the arrangement is neither clinically contraindicated nor exploitive.
• Balance adjustment issues
  • The rationale for, deblockedion of, and date of any balance adjustment made with either the client or a third-party payer should be part of the record. This can decrease the potential for misunderstandings or perceived obligations that might affect the relationship.
• Copayment issues
• Date, amount, and source of payment received
• Concerns about collection
  • Often also useful is documentation of collection efforts, including notification of the intention of using a collection service.

Disposition of Records

Certain events require collection, storage, transfer, or disposal of client records. These events are:
1. Unexpected events (disability, death, or involuntary termination of practice)
2. Planned events (retirement, closing a practice, voluntarily leaving employment)

Disposition of client records must be handled in such a way that confidentiality is maintained and client welfare safeguarded (American Psychological Association, 2007). This refers to all private information--written or unwritten--such as communications during the time of providing service, computer files, e-mail or fax communications, written records, and video-tapes. This means that the therapist needs to have suitable plans in place from the beginning of her job. Also to be planned for, in case of unexpected changes, are contingencies for continuation of services (Barnett and Zur, 2011).

In the circumstance of unexpected events, the plans might include control and management of closed records by an agency or trained individual. In the circumstance of planned events, depending on who the employer is, the provider may wish to retain custody and control of the closed records.

It may be helpful to have a method for notifying clients regarding any changes in the custody of their records, especially recently terminated services or open cases. You'll want to check legal and regulatory requirements to see if you should post a public notice about changes in this custody, such as a notice in the newspaper.

If records are to be disposed of permanently, they must be disposed of in such a way that they cannot be recovered, such as shredding. You must to provide for confidentiality in transportation to the shredding facility, as well as in that facility. This might require accompanying the records through the disposal process or having a confidentiality agreement with those responsible for the disposal.

Disposal of electronic records have unique challenges, because you may not have the technical expertise to fully erase or otherwise delete records before, as an example, disposing of an external back-up storage device or a computer hard drive or other electronic record repository. Even though efforts may be made to erase or delete records, they may still be accessible for some "geeks" with specialized knowledge. You'll possibly need to work with a technical consultant to find a satisfactory method for destruction of electronic records. These could include physical destruction of the entire medium or demagnetizing the storage device.

In spite of the awareness that a big part of supervision is the supervisor's evaluation of the supervisee, it's apparently something that is often far from the favorite task of a supervisor. Some of the reasons for this include (Lichtenberg et al., 2007):

• Defining competencies in precise and measurable terms
• Reaching agreement within the profession about the key elements of each competence domain
• Establishing an armamentarium of tools for assessing all components of competence, including the knowledgebase, skills, and attitudes (and their integration)
• Determining appropriate, agreed-upon minimal levels of competence for individuals at different levels of professional development and when "competence problems" exist for individuals assuring the fidelity of competency assessments
• Establishing mechanisms for providing effective evaluative feedback and remediation

But Lichtenberg et al. (2007) believed that "the single biggest obstacle would be convincing those who are skeptical of the value of … implementation of comprehensive competence assessments across the professional lifespan."

However, no matter what problems are related to it, supervisor evaluation of the supervisee is an established fact and must be faced. Interestingly, unless things have dramatically changed in the 21st century, supervisees frequently receive no evaluation until the last day of the required training, and then receive some negative feedback about which they had heard nary a word in the course of training. You can see why the lack of performance evaluation has been the most commone ethical violation reported by supervisees in supervision (Ladany and Lehrman-Waterman, 1999).

For contrast with the above list from Lichtenberg et al. (2007), the primary reasons given in 1993 of why supervisors often don't give negative feedback were (Robiner, Fuhrman, and Ristvedt, 1993):

1. Definition and Measurement: Supervisors reported concern about the methodology, reliability, and validity of the scales or measures they use, or they're concerned that anecdotal feedback does not meet criteria for accurate assessment.
2. Legal Liability: Supervisors were concerned with legal and administrative issues--legal liability if the supervisee would dispute the feedback (especially in light of the first concern, fearing the feedback may not be defensible).
3. Interpersonal Issues: Many supervisors feared that the evaluation might cause the supervisor to come under unwelcome scrutiny; they also feared that it might risk jeopardizing the supervisory alliance or interpersonal relationship established with the supervisee.

It's ironic that supervisees report that supervisors who give abundant constructive feedback and evaluation are their best supervisors (Falender, 2010). The Association of State and Provincial Psychology Boards (2003) suggested that summative evaluation be given to supervisees in written form four times during each training year.

Summative evaluations of supervisees would examine the outcome of their clinical work. It would include:

• Outcome evaluations that investigate whether the supervisee caused demonstrable effects on specifically defined target outcomes
• Impact evaluation is broader and assesses the overall or net effects--intended or unintended--of the supervisee as a whole
• Secondary analysis reexamining existing data to address new questions or methods not previously employed (Trochim, 2006)

A related type of evaluation is formative evaluation, which tries to improve or strengthen the person being evaluated. As it relates to supervisees, it examines their delivery of therapy or a social work program, the quality of this delivery, and assessment of the context. A formative evaluation includes:

• Praise or support
• Constructive feedback focused on suggestions or analysis
  • Thinking about what other options might have been helpful
  • Wondering about the rationale for particular interventions
  • Thinking more about process than content, effect rather than content, or generally refocusing the therapy process
  • Specific and directive for beginning level supervisees; more open-ended and thought provoking for more advanced supervisees

Current thinking is moving towards a 2-way feedback, where supervisees also evaluate supervisors. Supervisees might fear that summative feedback could influence their own evaluations negatively, and thus be cautious in giving summative feedback to supervisors. However if you, the supervisor, are truly open to feedback and accepting of it, it can be very helpful to both you and the supervisee. If, however, you respond with dismissive behaviors, resistance, or even anger, it will obviously not be a helpful process (Falender, 2010).

Options to aid effective competency-based evaluations:

• Track for outcomes in client progress; examples of a tool for this are Lambert's Outcome Questionnaire (OQ) and its child and adolescent equivalent (Y-OQ) and the other measurements that were discussed earlier in the course can be uses, such as depression scales.
• A self-assessment to assess and extend one's areas of practice, or just to see how current the supervisee's knowledge and skills are. Belar et al. (2001) offer a template that a supervisor can use to devise pertinent self-assessments for his specific use.
• Use a multi-source feedback (also known as "360-degree feedback"). The individual being rated (supervisor should do on himself first, then the supervisee would follow suit) first rates himself, and then is rated by peers, administrators, clerical staff, clients, supervisors (who were first rated by the supervisee), and others in the setting. The coordinating supervisor integrates the results to make a comprehensive feedback.
• The supervisor(s) should be certain that the evaluation documents include every important performance area in the supervisee's setting. If something is overlooked in the evaluation documents, it should necessarily also be overlooked in the final evaluations.
• Use other evaluation measures such as alliance measures, supervision outcomes, and diversity/multicultural competence assessments.

If the supervisee does not meet performance standards, she can be given an action plan for improvement, or in most drastic situations, a longer period of time of required supervision. Supervisees who don't meet standards after the action plan approach are rare (Falender, 2010).
[Question #47. Red flags for performance problems to pay attention to when evaluating supervisees do NOT include:]
a) Chronic lateness
b) Delinquent paperwork
c) No alterations in interaction style or behavior
d) Client cancellations (by client or supervisee)

Not meeting performance standards are reflected in professional functions in one or more of the following (Lamb, Anderson, Rapp, Rathnow, qneSesan, 1986):

• Inability or unwillingness to acquire and integrate professional standards into one’s repertoire of professional behavior
• Inability to acquire professional skills to reach acceptable level of competence
• Inability to control personal stress, psychological dysfunction, and/or excessive emotional reactions that may affect professional functioning
• Supervisees don't acknowledge, understand, or address the problem even when raised
• The problem is not just a reflection of a skill deficit rectifiable through academic or didactics
• The quality of intern service is consistently negatively impacted
• The problem is not restricted to one area of functioning
• Disproportionate amounts of attention by training personnel is required
• The intern’s behavior does not change as a function of feedback, remediation efforts, and/or time

After you've determined that the supervisee is not meeting performance criteria, and you've given feedback directly to him, work with the supervisee to develop a plan (based on data you can find in regard to successful completion of the behaviors in the past and factors that facilitated those) for change or completion. Construct a time-line with intermediate check-in points that are fairly close together, and document the meeting in which all of this took place (Falender, 2010).

The initial check-in should be within a few days of the meeting; be sure to follow up to see if appropriate progress is being made. Even with appropriate progress, continue monitoring even past indications that the behavior has changed. If the problem behaviors don't decrease, take appropriate steps that might include:

• Consultation with the school (a step that could even have occurred earlier)
• Consultation with Human Resources or Personnel Department
• Consultation with Administrative personnel on site
• Increased supervision or different supervision modalities
• Introducing a co-therapist
• Reducing workload or, if necessary, removing clients from caseload as needed
• Suggesting outside supports such as therapy or whatever is indicated
• Leave of absence

Continue with these steps until the problem is solved or until you determine that the supervisee's position must be terminated (Falender, 2010). All steps must be carefully documented.

Now you have completed Part 2, on to Part 3…