By: SOPHIA F. DZIEGIELEWSKI
Professional efforts require that all activities performed and judgments made are within an Ethical and Legal framework. Practitioners must avoid any hint of malpractice. Malpractice is negligence in the exercise of one’s profession.
All the legal requirements
and the problems that can occur is beyond the scope of this article. However,
professionals should
(a) Be aware of the rules
and requirements that govern professional practice activity in their state and
(b) Be well versed in the
code of ethics that represents their profession’s moral consensus (Reamer, 2001, 2009).
It is not enough for helping
professionals to assume that their ethical practice will be apparent on the
basis of their adherence to their professional code of ethics.
Two common sayings about documentation are:
1. If you documented it, it
happened.
2. If you did not document it, it did not happen.
2. If you did not document it, it did not happen.
When
documenting client information, be sure it is accurate and reflects the nature of the ethical services provided, as this can be the best way for mental health
practitioners to protect against malpractice. Practitioner documents must ensure that client confidentiality and privacy are protected (Dziegielewski, 2013).
One
helpful rule is to remember that at any time, all records may be subpoenaed in
a court of law, where private client information may be divulged. Regardless of the
employment setting, all helping professionals should consider maintaining personal
malpractice insurance in addition to what may be provided through agency
auspices.
Even with
the best of intentions, mental health practitioners may find themselves in legal
proceedings defending the content of notes, subjective assessments, or terminology
used in the diagnostic assessment.
It is
always best to record objective data and refrain from using subjective
terminology (i.e., what you think is happening). When documenting, always use direct client
statements; do not document hearsay or make interpretations based on subjective
data (Dziegielewski, 2008).
Practitioners
need to be familiar with specific state
statutes that do not allow professionals to elicit or document specific client information. For
example, mental health professionals are prohibited from documenting the
medical condition of AIDS patients without client consent.
In record
keeping, the ultimate legal and ethical responsibility of all written
diagnostic and assessment-based notes always starts and stops with the mental
health practitioner.
References
SOPHIA F.
DZIEGIELEWSK, 2015, DSM-5TM
in Action, by John Wiley & Sons, Inc.
No comments:
Post a Comment