Chapter 2: Therapy Records

Responsibility for 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.

[QN.No.#1. Keeping up clinical records is the responsibility of:]

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).

Content of Records

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):

• 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 confidentiality and authorization or consent for release of information
  • Documentation of any mandated disclosure of confidential 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
• 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
• 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

[QN.No.#2. Which of the following does NOT belong in the client's record?]

Medical and Psychiatric History

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. Using both overt and covert means, a mental status exam (MSE) will be given to determine the cognitive functions of:

• Orientation to person, time and place
• Spatial orientation
• Short- and long-term memory
• Concentration
• Abstract reasoning
• Judgment
• Following commands
• Simple math
• Word finding
• Naming objects
• Writing

[QN.No.#22. The mental status exam (MSE) is to determine the client's cognitive functions, including:]

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.