Legal and Ethical Issues for Mental Health Clinicians by Susan Lewis

Author:Susan Lewis
Language: eng
Format: epub
Tags: Legal and Ethical Issues for Mental Health Clinicians: Best Practices for Avoiding Litigation, Complaints and Malpractice
ISBN: 9781683730125
Publisher: PESI Publishing & Media
Published: 2016-09-02T16:00:00+00:00

Case Example

You have been working with an individual who has reported years of sexual abuse when she was a child by both her father and grandfather. She has recalled details of the abuse over time. You place the information in her medical record.

Your client has become involved in some legal proceeding where her mental state may be at issue. The medical records are called into court.

The client’s grandfather and father have come to court to support her. If the medical record is filled with details, all that information may be exposed in court. In addition, the accused perpetrators are in court. Certainly there will be legal maneuvering to block the information from being introduced into open court, but the results of the legal argument cannot be determined in advance and the court may order the entire record to be placed into evidence.

Previously, I detailed some of the requirements for record keeping under HIPPA laws. If you work in an institution, there are guidelines you must follow. Records can be idiosyncratic for the mental health work you are involved in.

Nonetheless, I would like to make some general suggestions about the information that you may include in a record. There are three component parts of information to place in a record. Those include identifying information, information for each contact with a client, and other relevant data.

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