Inland Empire Chapter of CAMFT

L&E: Ethics in Documentation: Moving Forward in a Digital Age 

Maelisa Hall, Psy.D, Licensed Psychologist

This presentation heavily emphasizes how documentation is an act of client care, and encourages clinicians to treat their documentation practices as client care rather than “administrative work” that may be overlooked, avoided, or viewed as less important than other clinical tasks. Furthermore, the presentation will review options for clinicians and provide standards based on ethical principles so clinicians can adjust their practices to better suit the needs of clients in a variety of scenarios or settings.

Case notes and client paperwork are commonly written in private and hidden away, making the experience confusing and anxiety-provoking for even seasoned therapists. Due to necessary limits to confidentiality, therapists rarely read one another’s notes as a matter of practice. Instead, notes tend to be available only at the request of the client or during situations commonly viewed as negative, such as during a board investigation or court proceedings.

This advanced workshop will provide direction based on ethical principles, but also a supportive format for discussing and practicing documentation in real time among colleagues. Most mental health professionals find the exercise of writing notes together to be cathartic and affirming, as well as informative. Attendees will be encouraged to evaluate their client population and modality when considering what best applies to their practice, and to share with one another throughout the workshop so as to establish a standard of care based upon ethical and legal principles.

Goals:

1. Create a progress note that incorporates applicable ethical guidelines.
2. Explain the concept of treatment planning and goals to clients in a meaningful and understandable way.
3. Describe the most common risks associated with clinical documentation and assess the acceptable level of risk related to use of technology.
4. Evaluate which laws and ethical principles to use in supporting individualized documentation practices.

Educational Objectives: Attendees will:

• 1.      Understand how to individualize and adjust documentation templates for the clinician’s preferences and client’s needs.
• 2.      Expand awareness of the documentation options available to clinicians and adjust documentation practices accordingly.
• 3.      Use technology to improve clinical practice while evaluating overall benefits and drawbacks for both clinicians and clients.
• 4.      Feel confident that case notes and treatment plans meet ethical and legal standards.

Bio:

Dr. Maelisa Hall is a licensed psychologist, serial entrepreneur and co-host of the My Biz Bestie podcast. Through her online continuing education courses at QA Prep, she encourages professionals to consider WHY they are creating policies or doing things, rather than copying from others or repeating what they have heard in the past. She enjoys creating trainings that are interactive and engaging so that clinicians leave with strategies they feel ready to use immediately.

Interview with Dr. Hall on YouTube

Ethics in Documentation Documents

Law and Ethics-Ethics in Documentation Eval Summary.xlsx