ERIC ED337719: Documentation in Counseling Records. AACD Legal Series. Volume 2.

78 Pages·1991·2.5 MB·English

by  ERIC

DOCUMENT RESUME
CG 023 714
ED 337 719
AUTHOR
Mitchell, Robert W.
Documentation in Counseling Records. AACD Legal
TITLE
Series. Volume 2.
American Association for Counseling and Development,
INSTITUTION
Alexandria, VA.
ISBN-1-55620-084-6; ISSN-1053-9549
REPORT NO
PUB DATE
91
NOTE
78p.
American Association for Counseling and Development,
AVAILABLE FROM
5999 Stevenson Avenue, Alexandria, VA 22304 (Order
No. 72022: $11.95 each).
Guides - General (050)
PUB TYPE
MF01 Plus Postage. PC Not Available from EDRS.
EDRS PRICE
Accountability; *Case Records; Communication (Thought
DESCRIPTORS
Transfer); Confidentiality; *Counseling; *Counselors;
*Documentation; Human Services; Legal Responsibility;
Records Management; Writing Skills
ABSTRACT
This monograph about accountability and communication
in record keeping is intended for human services professionals. Eight
terms are defined in an introductory glossary. The first section
discusses the purpose of records. The next section discusses clarity
in staff notes. Key points are offered for effective communication
through staff notes. The next section focuses on the causes of
ineffective communication and on increasing risk exposure. One of the
most effective tools for avoiding litigation is utilizing clear
communications, particularly for records. The text section analyzes a
staff note, noting that a frequent problem is that entries are too
short and vague. Learning to write a substantlal note in a few
sentences is important. Examples of the need for clarity and
precision are the focus of the next section. The counselor's written
words are the only record of a session with a client, and therefore
need to be written accurately. The next section discusses ways of
responding to an outside inquiry. Letters responding for outside
requests for information demonstrate the counselor's professionalism
and expertise. The essentials of the plan of care, care review, and
staff notes are considered in the next section. This is followed by
analysis of a group note. The next section evaluates a plan of care.
Confidentiality and other legal issues aro discussed in the next
section. The final section provides answers to frequeltly asked
questioas. A summary, discussion questions, and referes.^es and
suggested readings are included. (LLL)
***********************************************************************
Reproductions supplied by EDRS are the best that can be made
from the original document.
***********************************************************************
"
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"PERMISSION TO REPRODUCE THIS
MATERIAL IN MICROFICHE ONLY
HAS BEEN GRANTED SY
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Robed W. Mitchell ACSW
TO THE EDUCATIONAL RESOURCES
INFORMATION CENTER (ERIC)."
Series &Roc
Theodore P. ihmiloy, Jr., JD, PhD
2
BEST COPY MAILABLE
THE AACD LEGAL SERIES
Volume 2
"DOCUMENTATION IN
COUNSELING RECORDS"
Robert W. Mitchell, ACSW
Series Editor
Theodore P. Rem ley, Jr., JD, PhD
(111
American Association for
Counseling and Development
Counseling and
Copyright 4'' 1991 by the American Association for
Development
All rights reserved.
American Association for Counseling and Development
5999 Stevenson Avenue
Alexandria, VA 22304
Cover Design by Sarah Jane Valdez
Data
Library of Congress Cataloging-in-Publication
Mitchell, Bob, 1937
American Association for Counseling and Development
%
Documentation in counseling records / by Bob Mitchell.
cm.(AACD legal series : no.
p.
Includes bibliographical references
ISBN 1-55620-084-8
2. Psychiatric social work.
1. Mental health counseling.
States.
3. Medical recordsLaw and legislationUnited
I. Title. II. Series.
RC466.M57 1991
91-2279
651.5'04261'024616de2O
CIP
ISSN 1053-9549
AACD Legal Series Volume 2
Printed in the United States of America
4
This book is for every person who has
ever tried to help someone.
Each of you makes a difference. You always have and
you always
will.
71
Special Thanks
To my parents, Isabel and William Mitchell,
for teaching me
that if something is worth doing, it is worth
doing well.
To Carolyn, Debbie, and Rob,
my family, for support.
To Rita Gray Recktenwald, for friendly, but
firm editing.
To Suzanne Wade, for patient
manuscript preparation.
To Mary Ann Main, JD, for legal consultation.
To Bob Pilkington for friendship and advocacy.
To Theodore P. Rem ley, Jr., for
encouragement.
Robert W. Mitchell. ACSW
Contents
Biographies
ix
Preface
1
Glossary
3
The Purpose of Records
5
Clarity in Sta'T Notes
111.
Ineffective Communication and Legal Trends
17
Analysis of a Staff Note
25
Factors Vital to Clarity
29
Responding to an Outside Inquiry
33
The Essentials of the Plan, Review, and Note
Analysis of a Group Note
43
Evaluation of a Plan of Care
49
Cnnfidentiality and Other Legal Issues
53
Frequently Asked Questions
59
Summary
65
Discussion Questions
67
.
References and Suggested Readings
71
Biographies
Robert W. Mitchell, ACSW,
was selected in 1988 as Social
Worker of the Year by the Kentucky Chapter of the National
Association of Social Workers. He has 31
years of experience in
human services, 18 of which were in direct service and
super-
vision. His first job was with Children's Protective Services.
He
also worked with programs focusing
on family problems, chem-
ical dependency, mental retardation, and psychosocial rehabil-
itation. From 1979 through 1982 he
was manager of the accounts
receivable department for Seven Counties Services, Inc.,
one of
the nation's largest comprehensive mental health, mental
re-
tardation, and substance abuse agencies. From 1982 through
1990 he was also a member of the Institute for Internal Auditors.
He is a member of the National Association of Social Workers
and a founding member of the American Association for Ther-
apeutic Humor.
A combination of clinical and fiscal experience gives Mr. Mitchell
a unique perspective. Since 1981, he has trained over 25,000
human services professionals in 32 states and Canada through
his documentation workshop. That workshop, the basis for
this
monograph, has been sponsored at two national meetings by the
National Association of Social Workers Malpractice Insurance
Trust and Legal Defense Fund. He has also presented
papers at
annual conferences of the National Council of Community Men-
tal Health Centers, the International Association of Psychosocial
Rehabilitation, the National Association of Social Workers, the
8
Association of Mental Health Administrators, Lhe Canadian
Mental Health Association, and the Institute for Human Be-
havior.
Theodore P. Rem ley, Jr., Series Editor, is Executive Direc-
tor of the American Association for Counseling and Develop-
ment. Immediately prior to assuming this position, Dr. Rem ley
Counselor Education at Missis-
was chair of the Department of
sippi State University in Starkville. He holds a PhD from the
Department of Counselor Education at the University of Florida
in Gainesville and a JD in law from the Catholic University of
America in Washington, DC.
9
Preface
In 1981, I began giving workshops
to human services profes-
sionals about accountability and communication in record keep-
ing. Since that time, people have been suggesting that I
put the
workshop into a book format. What
you are about to read is
based on more than three decades of experience in the field,
including a wide range of clinical and auditing responsibilities
as well as consultations with auditors, third-party payers, licen-
sure review teams, medical records personnel, counselors, and
lawyers. Some of these professionals had worked for organiza-
tions that had gone bankrupt because of insufficient documen-
tation. Printed materials, titled and untitled, also aided in the
development of the workshop and this monograph. Although it
is impossible to credit each source of information, the monograph
contains a list of references and suggested reading materials,
some of which influenced the development of this work. When
actual records are used, only dates and
names have been changed.
The text is written in the first person because it is
my style, and
I want you to know that I am talking to
you.
This monograph does not provide
a fail-safe solution to all
record-keeping problems. Certainly, it is not
a substitute for
competent legal advice. Ultimately the best records system for
you is one you have designed for yourself, your clients, and your
agency. But I believe you will find the informati )n useful. You
may not agree with everything. Or some things may not be
applicable to your work. But
one thing is necessary: an accep-
tance of the need for excellence in record keeping.
10