Record keeping is an important aspect in any area for example where a therapist deals with various clients in day to day undertakings. It is not only ethical but it is also legal.
Record keeping is very helpful especially when one is involved in a legal battle with a client in cases where a client needs some clarification on various issues especially those related to health or any other aspect of life. In the area of health, it is ethical and legal for a mental health practitioner to keep adequate and current client’s records.
Record keeping provides an important framework that a therapist uses in reviewing treatment. The law also requires keeping records safely. Accurate and detailed health records especially clinical records provide defense that can guard against malpractice claims. Documentation of clinical or health services serve an important role especially for mental health professionals.
In medical profession it is important to gain clients trust. This can be done especially by making them aware of how certain information related to their health can be used helpfully by the government and insurance companies. The clients should be explained the confidentiality of their records and up to what extent these confidentiality can be compromised. Sometimes it is necessary for therapists to disclose confidential medical information of clients.
The practitioner should sometimes know that client’s records come under intense scrutiny and review when a practitioner contracts with a third-party payer. In some cases confidentially of the records is not absolute. Some circumstances will demand that a practitioner discloses the records. Record keeping helps to improve healthcare practitioners’ skills and provision of effective treatment for clients. Clinical records reflect conditions of clients at particular moments making record keeping a standard of care practice by professional organizations.
Legally, due to much awareness of potential liability, there is need for comprehensive documentation. It is a wise policy for practitioners to document their undertakings with clients in crisis situations that may involve harm to oneself, others or property. It is therefore unethical and illegal for health professionals not to keep records.
It is ethical for practitioners to keep, maintain and store records safely and in a way that retrieval is possible. This is expected of a mental health professional whether the records are active or inactive.
It is worth noting that information in the clients’ record belongs to him or her and may be required anytime. It is therefore necessary for a practitioner to treat a client with due respect. It is necessary for practitioners to take responsibility for what writing, storage and access to the records. Clients’ records must be treated confidentially.
As a medical practitioner, it is possible to adopt a substandard approach to record keeping. Sometimes due to limitations in time, it is possible to avoid keeping records. Clinicians sometimes become extremely busy making record keeping of clients hectic. It sometimes makes practitioners to avoid keeping notes since they believe that they can remember what clients tell them. Keeping records is demanding and needs dedication. It is therefore hard for a busy practitioner to maintain an up to date record for clients. This is a big challenge for many practitioners.
However regardless of the time taken for record keeping it is necessary both legally and ethically for any practitioner to keep records of clients.
Corey, G., Corey, M.S. & Callanan, P. (2007). Issues and Ethics in the Helping Professions. (7thed.) USA: Thomson Books.
Tribe, R, Morrissey, J. (2004). Handbook of Professional and Ethical practice for psychologists, counselors and psychotherapists. New York: Brunner-Routledge.