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Event ID: 2541838
Event Started: 2/17/2015 10:46:33 AM ET
Good morning everybody. This is during. This is the University of North Texas. You are here this morning to join us for one hour presentation on the ethics of documentation. And that is what you are looking for, you are in the correct webinar. We have quite a few people on already. We have a few more coming in. Just some basic information about the webinar while we wait for people to come online and make sure that we can hear each other.
Thank you. Hopefully everybody can hear us okay. For those of you that may be new to this process, if you go through your control panel you'll see a button called questions. You can write questions and let us know if you have any comments. For now, just give us a good morning to let us know you can hear me.
Good morning.
If you can hear her voice okay, then that is super. As a reminder, this is a webinar on documentation. Dr. Catalano is a graduate coordinator of the department of disability and --. She comes to us from Wisconsin which I believe, right now, it is pretty darn cold right now. She is a certified we dilatation counselor. Her areas of interest include social aspects of disability, adaption disability. We've seen a lot of people with spinal cord injury or erratic brain injury. She has a lot of information to share with us. This is a critical function of what we do as both employment service professionals and rehabilitation professionals.
You are with us for a full hour.
Hello everybody. Looking forward to talking with you. It is something every but he has to do. We have to do something, it put some perspective on it. That is what I want to focus on. Looking at the ethical standards about documentation and going over some information that I have gathered, over time, about the importance of records and what needs to be in records.
I taught at the undergraduate level, but I continue it at the graduate level. At the end of the semester I always hear from students that they say that they didn't know it was a lot of work. It's hard to document the important things you are doing with the clients you are working with. What I am hoping is that toward the end of the presentation I have a couple of models for casenotes that might be able to help you. I know a lot of agencies have certain formats that you have to follow.
I understand that. When I worked for the department of rehabilitation, we didn't have a format, we had an electronic case management system. We had test boxes that we had to fill and. Some case managers -- fill in. Some case managers put minimal information and and others put a lot. Either way it's difficult. It is difficult to review where the counselor and consumers are asked so you do no harm.
Casenotes is critical. And reading through our code of professional ethics, I couldn't help but think that there isn't anything in here that doesn't relate to kiss documentation. Even if it is not specific about the format or standards, it is the work that you do with your client. That has to be reflected in the record. Sit back. I hope you enjoy the presentation.
I get an email that shows that some of the discussion topics that are going on. I thought I would share some of the perspectives. Head is from the students in our program. Again, I hope these models of case notations might help. The time to counsel and guide takes a backseat the paperwork. They get more positive. Like the fact that it went to a positive direction.
I have been in social services 20+ years and remember going through narratives and dictation and computers. Technology makes amazing improvements for some customers. I feel lucky to still be able to do my job. My clients make it worthwhile. What a wonderful way to and a discussion board that started out like, negative, to positive. Look at how we continue to make a difference in the lives of people with disabilities. I thought it was interesting. People were talking about that on the CRC website as well. First, I want to review the purpose of case notes and then we will talk will be ethical standards related to case records and then show a connection between casenotes and the quality of client services. I can't help but think, as a case manager, you are putting out fires. I always thought, how do I get ahead of this.
I can't help but wonder if I had spent more time making sure I was reviewing casenotes and making sure I was following up on than that I had so many fires or did they occur because I didn't realize that something was supposed be done that did not get done. Had I seen that in my casenotes, would I have avoided that?
Finally, we talked about some strategies for case documentation and then some current and future ethical considerations.
Let's talk about the purpose of casenotes. Some of this will be obvious, but maybe there is something in here that I can present from a different perspective. First of all, the purpose is, because we do have an ethical responsibility to respect the dignity and welfare of clients.
How are they progressing toward the goal? We need to promote their welfare. That is the primary purpose of casenotes. Client progress is certainly the purpose of the casenotes. Also, for provisions. Many supervisors will review client case files. There may be auditors that come in. People from other agencies that are being funded. Those auditors will come in and review the casenotes as well to make sure that you are doing the policy of that agency. A supervisor will make sure that you are meeting the needs of the client and so forth. Many of you probably work with students. Away help students learn the skills, they can see how you do your casenotes and what needs to be in their work. How do you reflect the client progress in writing. And then, of course, the assessment of outcomes.
I'm sorry. I keep hitting this rock in my throat. So, assessment of outcomes. Obviously, that is a critical feature. The casenotes must reflect how you are proceeding towards the goal and what are the outcomes of the services you are providing. You should be able to look back and see what are the most effective services and be able to do your own assessment of the outcomes to see what is most effective, what wasn't effective, and so you want to not only reflect the outcomes of your client but you can use that information for your own program evaluation as well. And then, of course, continuity of services. Case managers come and go. I took over from somebody who has been doing a caseload for 23 years. Stepping in, I had over 200 clients. There was no way I was going to start from scratch. Those casenotes had to give me the information I needed so I could step in and continue to progress. And then, there is a forensic uses of casenotes. The always have to be written with the understanding that you don't know who will have to use the casenotes. If they went to a court of law, would it be within the clients interest or did you cause harm?
There will always be ethical dilemmas. I always like to bring in the idea that there will always be ethical dilemmas. You are not always expected to make the correct decision but you are expected to make the best possible decision given the available information. That is all any of us can really do. Was to importantly, that decision-making process has to be documented. What needs to be documented is, what exactly is the dilemma? And, who did you consult about the dilemma? One thing about this, as you know, there are the ethical principles.
What happens within an ethical dilemma is that you choose one course of action to be compliant with one particular principle and then another ethical sensible could be violated. So, either direction you go, you will violate an ethical principle. Is happens all of the time. Document something or not? There is an ethical dilemma right there. Will it cause the client harm are good? Will it help the client and the progress toward their goal? You are always making these decisions. What you need to do, obviously, is determine what will cause the least harm.
There are ethical decision making models out there. In our code it means that ethically you should use ethical decision-making models when trying to decide what course of action to take. So in your casenotes have to document all of those. Again, what is the dilemma? What is in conflict? What are you trying to achieve? Who did you consult with? Did you consult with the code of ethics or the supervisor? What was the degree of consensus? Did you get enough information to know what to do? What was the decision that was made and then what is the justification and advantages of the decision over other courses of action. Again, you will not know who will look at those casenotes. They will want to know how you came to the decision you did.
One of the main ideas is informed consent. There is a requirement, and ethical requirement that you provide your clients with a professional disclosure statement. There actually is one available on the website, depending on what the nature of your agencies are. I can pull this link up. For example, if you are working in the public sector, if you are doing this, then you could pull of this template for a professional disclosure form. It tells you all of the information that you need to include. This may not be all the information you tell the applicants when they are first starting to receive services, but as I know from my classes, they may remember what I said at the beginning of class, and they may remember what I said at the end of class. But, what took place within the middle?
It doesn't really sink in. That is why we now use PowerPoint. That is why we give thanks to people in writing so they can remember what the details are of the things we discussed. So, with the professional disclosure statement what you can do is, make sure you put in there all the information. Make sure the consumer walks away with information that they need. There is a lot of information in there. You fill this in. Many agencies may already have a disclosure form that you are required to use for your agency. That is fine. What I was just is that you take a look and see whether or not these forms are consistent with what CRC see -- what CRCC is recommending.
There is a lot of great information in the CRCC website.
This statement is critical. We recommend that you make sure whatever information you give the consumer that you give it to them and writing. And needs to be given to the consumer in such way that they understand the risks and benefits of receiving services. That they have the capacity to understand the fact, risks, and benefits. And, engaging in the services is voluntary. It is their choice to receive these services. The main ethical issue that I often go over and class is the idea of benefits analysis.
Many consumers are receiving Social Security and what does employment mean to them in terms of how that might impact their benefits. I have always maintained the perception that, doing a benefits analysis is an ethical responsibility. They need to know how they will be impacted. That is a risk of receiving services that will help them become employed. So, you need to let them know how the information they are giving to you going to be shared with others. For example, your supervisor. The client should know that your supervisor can look at your casenotes.
The auditor might walk in and take a look at the casenotes. It could be subpoenaed by a court. Of course, there's confidentiality in terms of, or the saying anything that might cause them self harm or maybe there is abuse going on of a child or the elderly. These are things that you must have in your professional disclosure statement to let them know that this is a possibility. When we talk about things I have to report this. But, you also have to know how the records will be stored.
I'm just making assumptions here, but I was a counselor back in the early 2000's. We had electronic files. Everyone was trying to go paperless. It was kind of a nightmare to convert but everything was electronic. What that meant was, I would need to tell my consumers that might case assistant can have access to the file. Anybody that worked in the state of Wisconsin in the agency, if they start -- searched for your name, they can pull up your record. So, it is only ethical to let the client know that there is a possibility that people in the agency will have access to the record. Again, this is part of informed consent. They need to be able to choose whether or not they need -- want services. So again, we have an ethical responsibility to maintain records. They have to be sufficient records to know what the goals are, what types of services, etc. They need to be timely.
I don't know what people's habits are, but if you wait until Friday, which is something we did in our office. Friday was case management they. That was the date you didn't schedule appointments any major you got you paperwork done. Well, if I interviewed somebody on Monday or Tuesday a lot of the nuances and subtleties, if I didn't put it in my notes, I will not member it on Friday. If I can make my casenotes after I met with each client and allow enough time to be able to do that than it is done. I can shred my notes and move to the next client. On the other hand, there was another extreme.
Some counselors took the casenotes while they were interviewing the client. I personally would not be able to multitask like that. I know -- I don't know if they were not paying enough attention to the client. Then, they could print out the casenotes to client. Both parties knew what was expected to happen before they met the next time. There was a benefit to that. And, she got her casenotes done. That is not a bad thing to maybe consider. Like I said, I cannot multitask like that. There must be a reflection of progress. You also have to talk about errors about when the errors were corrected. You can't just delete things. So, you need to state when things were corrected. And then of course there needs to be confidentiality. Only authorized people should have access. Then that begs the question, who has access to the records?
In the purchasing department look at the records? So, these are all things that need to be discussed with the client. This is all part of informed consent. And then, does the client to have access to the record? Of course. Maybe agency policies cover this. It sometimes depends on the record. Psychological records might be best with the psychologist that did the assessment and wrote the report. Again, there is an ethical decision there. If I just hand the file over, will that cause any harm to the client or is this a benefit to them and they should see what is in the record because they are a partner and they should be informed.
These are things you need to talk about with the client. Certainly you have to have disclosure, a written release. Then, when do you dispose of the records? How long do you hang on to those records? Is there an agency policy? Do you hang on to them for five years? To state regulations require at least five years? Do they get disposed at that time? Who disposes them? What is the requirement? And then, making sure there are reasonable precautions for confidentiality and the result of a disaster. We all heard about hurricane Katrina where offices were demolished. What happened to the records? One of the benefits of electronic records is that perhaps they are stored somewhere that is safe but not if they are on a server in the office and the server gets demolished as well. These are all things you need to think about and talk about with the client in terms of confidentiality. Now, we know that we keep electronic records. We sometimes have communication with our clients through modalities that allow for talking over the phone or Internet. So, our ethical standards address these.
They will be revising these standards. These have been in place since 2010. It is already 2015. They are already working on some revisions. From what I heard from conferences, the biggest area that will have to be addressed is, how do we handle technology because, that has things that we did 10 years ago, we wouldn't even imagine today that we would be using Skype with clients over the Internet because they live in a rural area and they can't come into the office. Now we can have face-to-face communications. Again, what does that mean in terms of, how secure is the information that is being conveyed over an Internet service and what does it mean? These are all things that you have to let the client know are possibilities of others getting access. I don't even know how they do that. But obviously missing as possible. We need to be aware of that. Again, we haven't technology and distance standards, if considered confidentiality, informed consent, security, transmitting confidential information, the security of information and then how records are managed. So, for example, in confidentiality and informed consent you have to be able to explain the limits of technology. You may need help from your agency and so forth. What are the limits? And then, you need to be able to talk about retention policies.