Acurate Record Keeping - Importance and Purposes of Counseling Record Keeping

Providing accurate records is essential to the mental health profession, recording the need for services, the treatment plan, the course of treatment, and the process of termination" (Drogin, Connell, Foote, Sturm, 2010, p. 237)

"Providing accurate

" Providing accurate records is essential to the mental health profession the records serves as a guide for treatment, records the need for services, for the treatment plan, the course of treatment, and the process of termination" (Drogin, Connell, Foote, and Sturm, 2010, p. 237).

From: barbara bryant <bjk75238@yahoo.com>

To: barbara bryant <bjk75238@yahoo.com>

Sent: Friday, July 6, 2012 8:52 PM

Subject: Andrea paper

Completing paperwork can be a tedious and less fulfilling task for many counselors. However, professional documentation is a major component of the counseling process. Records benefit both the client and the counselor through documentation of case conceptualization, treatment plans, services provided, and client progress. Efficient, accurate records can also help protect both the client and the counselor in the event of legal or ethical proceedings.

This paper will explain the importance of record keeping and the purposes of keeping comprehensive client records. In addition, this paper will describe potential ethical and legal consequences of not keeping appropriate counseling records. The final section of this paper will provide an analysis of the ethical conflicts that could arise from the court-ordered reporting of counseling records.

Importance and Purposes of Counseling Record Keeping

Good clinical case documentation and record keeping are an important part of ethical practice. The ACA Code of Ethics (2005) and the American Mental Health Counseling Association (AMHCA) Code of Ethics (2010) show a variety of circumstances that emphasize the critical nature of recordkeeping: reporting suspected child abuse, implementing a counselor's duty to inform or protect when a client is a danger to self or others, or when clients are involved in legal proceedings. Each of these situations requires appropriate recordkeeping.

According to Remley and Herlihy (2010) client case notes or records are defined as "any physical recording, [such as printed or electronic, and audio or video recordings], made of information related to a counselor's professional practice" (p. 129). For example, an important part of a mental health counselor's work is documenting what goes on during intake interviews and subsequent sessions. The American Counseling Association (ACA) Code of Ethics (2005) requires counselors to "maintain records necessary for rendering professional services to their clients and required by laws, regulations, or agency or institution procedures" (Section A.1.b.).

This standard is the principal reason for keeping records, which is to assist in delivering the most beneficial counseling services to the clients.

In addition, Remley and Herlihy (2010) state that adequate record keeping helps clinicians to stay on track by documenting why particular courses of action were taken, and provides baseline information for evaluating progress of clients. "Records may serve as useful roadmaps for treatment, documenting the need for services, the treatment plan, the course of treatment, and the process of termination" (Drogin, Connell, Foote, & Sturm, 2010, p. 237).

Additionally, good documentation can be also be very helpful, especially when a client or the counselor goes on an extended break, or transfers to another counselor (Record Keeping Guidelines, 2007). Imagine, trying to accurately recall the details of a client's life, after not seeing the client for several months without good case notes. Also, for treatments that include multiple, integrative type therapies, sufficient records build connectivity between professionals and allow for a mutual comprehending of the client (Remley & Herlihy, 2010). Likewise, when clients transfer to different counselors, the new counselor should have access to the client's case history, to include diagnosis, treatment, therapeutic successes, and limitations, which will help the practitioner to provide better services (Remley & Herlihy, 2010).

Remley and Herlihy (2010) suggest that counselors "balance their need to keep documents with their obligation to provide

...