Recordkeeping

Recordkeeping is, in some way, the executive branch of counseling and its benefits are far-reaching for the client as well as the counselor. The ACA Code of Ethics (2005) requires counselors maintain client records that support the counselor's ability to monitor progress and provide ongoing adequate and organized service to the client. These records help the counselor maintain congruous and consistent direction within the therapy (Laureate Education, Inc., n.d.) Despenser (2004) states adequate recordkeeping according to appropriate policies helps the counselor keep a legal record of interactions with clients and their therapeutic progress. Keeping records also helps counselors keep track of therapies as well as interventional techniques, why they were implemented, and the effect they had on the client. Good recordkeeping works as a roadmap, of sorts, tracking clients' needs, the plan for their intervention, and their progress (Drogin, Connell, Foote, & Sturm, 2010). I suppose it is important to mention that if counselors fail to maintain adequate records, it can affect their right to protection in litigation as well as in mandated reporting, cause the imposition of penalties, and in some cases, the forfeiture of their license to practice (Remley & Herlihy, 2001).

A variety of circumstances underline the critical nature of recordkeeping: when counselors must report suspected child abuse or when dutifully warning others or protecting a client from themselves, counselors must present adequate records that substantiate their reasoning. Furthermore, when clients are involved in any type of legal proceedings, counselors may be required by law to submit portions or the entirety of records pertaining to the client. Each of these situations require appropriate recordkeeping. The one particular situation I will focus on for the purposes of this discussion, however, is if and when clients' records are legally subpoenaed.

In court-ordered circumstances, counselors may be legally obligated to provide documentation of detailed personal and sensitive information obtained during counseling, even when the counselor believes providing such information may not be in the client's best interest or may be detrimental to the client (ACA Code of Ethics, 2005). When counselors' ethical obligations conflict with legal ones, the counselor should remain committed to the ethical codes of the profession and take appropriate steps to mitigate the conflict. If the conflict defies resolution, they must fulfill their legal obligations (Committee on Legal Issues, American Psychological Association, 2006).

The counselor is obligated to provide the documentation although the obligation is limited to essential and pertinent information. Furthermore the counselor can try to prohibit or limit such disclosure when he or she believes releasing the information is harmful to the client. Counselors do, in fact, have an obligation to uphold legal requirements and government authority (ACA Code of Ethics, 2005). Seeking legal counsel is in the client's as well as the counselor's best interest in cases in which the court subpoenas the counselor's confidential documentation.

Understanding that my notes or any reports that come from counseling an individual, may end up as part of a lawsuit or some type of legal proceedings. Certainly part of informed consent should notify clients that anything they say, or the records kept on their behalf may, at some point, be evidentiary in a court of law. For the counselor, this may mean creating records that include limiting sensitive client information. Zuckerman (2008) recommends not including information from previous reports or the reports of other professionals. Furthermore, abridging notes and records can be helpful in sensitive situations, for example, when confidential information is subpoenaed. It is important to refrain from keeping confidential records that serves no purpose in therapeutic process. Including superfluous confidential information in the therapeutic environment is not beneficial for the client, and the first responsibility is to the client (Zuckerman, 2008).

I agree with Buckley in this week's video (Laureate Education, Inc., n.d.) when he states that he does not want to write his notes in fear of a lawyer of other institution reading them, but, on the other hand, counselors must understand the possibility exists that confidential information may be compromised in cases of litigation or other legal proceedings. Writing notes and keeping records with the legal system in mind will ultimately benefit the client as well as the counselor.


References:

American Counseling Association (ACA). (2005). 2005 ACA code of ethics [White Paper]. Retrieved from the ACA website: http://www.counseling.org/Files/FD.ashx?guid=ab7c1272-71c4-46cf-848cf98489937dda

Committee on Legal Issues, American Psychological Association. (2006). Strategies for private practitioners coping with subpoenas or compelled testimony for client records or test data. Professional Psychology: Research and Practice, 37(2), 215-222. doi: 10.1037/0735-7028.37.2.215

Despenser, S. (2004). Case notes in private practice. Counseling & Psychotherapy Journal, 15(6), 40–44.

Drogin, E. Y., Connell, M., Foote, W. E., & Sturm, C. A. (2010). The American Psychological Association's revised “record keeping guidelines”: Implications for the practitioner. Professional Psychology: Research and Practice, 41(3), 236-243. doi: 10.1037/a0019001

Laureate Education, Inc. (Producer). (n.d.). The Application of Ethical Guidelines and Laws To Record Keeping [Streaming Video]. Baltimore: Author.

Remley, T. P., & Herlihy, B. (2001). Chapter 6, Records, Subpoenas, and Technology. In Ethical, legal, and professional issues in counseling (pp. 129-163). Upper Saddle River, NJ: Merrill Prentice Hall.

Zuckerman, E. L. (2008). The paper office (4th ed.). New York, NY: Guilford Press.