PDF DOCUMENTATION inCOUNSELING RECORDS
[Pages:24]THIRD EDITION
DOinCUMENTATION COUNSELING RECORDS
An Overview of Ethical, Legal, and Clinical Issues
Robert W. Mitchell, ACSW
AMERICAN COUNSELING ASSOCIATION 5999 Stevenson Avenue Alexandria, VA 22304
THIRD EDITION
DOCUMENTATION in COUNSELING RECORDS
An Overview of Ethical, Legal, and Clinical Issues
Copyright ? 2007 by the American Counseling Association. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the written permission of the publisher.
10 9 8 7 6 5 4 3 2 1
AMERICAN COUNSELING ASSOCIATION 5999 Stevenson Avenue, Alexandria, VA 22304
DIRECTOR OF PUBLICATIONS Carolyn C. Baker
PRODUCTION MANAGER Bonny E. Gaston
COPY EDITOR Christine Calorusso
EDITORIAL ASSISTANT Catherine A. Brumley
Cover and text design by Bonny E. Gaston.
LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Mitchell, Robert, 1937?
Documentaltion in counseling records: an overview of ethical, legal, and clinical issues/by Robert, Mitchell.--3rd ed.
p. cm. Includes bibliographical references. ISBN 13: 978-1-55620-273-5 (alk. paper) ISBN 10: 1-55620-273-3 (alk. paper) 1. Mental health counseling. 2. Psychiatric social work. 3. Medical records-- Law and legislation. I. American Counseling Association. II. Title. [DNLM: 1. Medical History Taking--methods--United States--Legislation. 2. Counseling--United States--Legislation. 3. Ethics, Professional--United States--Legislation. 4. Medical Records--United States--Legislation. WB 290 M681d 2006]
RC466.M57 2006 362.2'04256--dc22
2006027652
Dedication
This book is for every person who ever tried to help someone. Each of you makes a difference.
You always have and you always will.
Contents
Preface
ix
About the Author
xv
Special Thanks
xix
Glossary
xxi
CHAPTER 1
Ethical Behavior, Values, and Professional Standards 1
Ethical Conduct
1
Enforceable and Aspirational Guidelines
5
CHAPTER 2
A Legal Perspective
9
Credentials
10
Charting Essentials
10
Testimony and Documentation
12
Missing and Incomplete Entries
16
Altered Documentation
16
The Record as Legal Defense
17
Eight Ways to Guarantee a Lawsuit or
Allegations of Unethical Conduct
18
CHAPTER 3
A Fiscal Perspective
19
What Not to Do
21
What You Must Do
21
Essential Elements for the Staff Note
23
Guidelines for Ethical Billing
25
v
CHAPTER 4 A Coworker's Perspective Conclusionary Terms, Modifiers, and Abbreviations Problematic Staff Notes Possible Repercussions Clear, Accurate Staff Notes
CHAPTER 5 A Client's Perspective Double Standards Cultural Diversity
CHAPTER 6 Online Counseling and Electronic Records Online Counseling Services and Safeguards Electronic Record-Keeping Guidelines
CHAPTER 7 Sexual Relationships and Dual Relationships Sexual Relationships and Ethical Conduct Dual Relationships in the Counseling Process
CHAPTER 8 Documenting High-Risk Cases Qualifiers, Violence, and Threats of Violence Homicidal and Suicidal Clients Physical and Sexual Abuse Criminal Behavior Permission for Service Form Additional Considerations Need for Specificity
CHAPTER 9 Terminations The Termination Letter The Termination Summary Abandonment Right to Refuse Service
vi
Contents
27
28 29 30 31
35 36 37
41 42 45
53 53 57
61 62 62 65 65 66 67 69
73 74 75 76 78
Contents
Frequently Asked Questions About Documentation
81
Multiple Uses of a Record
81
Subpoenaed Records
82
The Unofficial Chart
82
Brochures and Informational Flyers
83
Preprinted Forms
84
Client's Use of Slang and Vulgar Language
84
Faxed Client Information
85
Terminations and Nonpayment
85
Missing or Lost Documentation
86
Filing Systems and Security
87
Cosignatures, Credentials, Students
and Volunteers
88
HIV/AIDs
89
Disclaimer Forms
91
HIPAA Basics
92
Risk Exposure
94
What Would You Do?: Ethical Considerations
95
Scenarios for Discussion and
Professional Development
95
Six Steps for the Resolution of Ethical Problems
99
Concluding Thoughts
100
Epilogue: You Make a Difference
101
References, Suggested Readings, and Web Sites
105
vii
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