Date - Wednesday, April 26, 2023
1:00 pm EDT - 4:15 pm EDT
Zoom Interactive Workshop
CE Credits: 3
Price: $ 90
See Outline Below.
Register for this ZOOM Workshop at your convenience. We will use your name and email contact information from your PayPal payment / registration. The day before the Workshop, we will email you a reminder, and a special link for you to use to join the Workshop.
Should I Write it Down?:
Ethical and Legal Ramifications of Documentation Decisions
A ZOOM Live Interactive Workshop
Rebecca Vauter, Psy.D., ABPP, Clinical Psychologist
Former Member of the Virginia Board of Psychology
I. Why do we document?
A. Protect the client
B. Protect ourselves/risk management
C. Communication among team members
D. Practitioner accountability
E. Provide structure, focus, and organization in our work
F. Comply with legal, regulatory, and institutional requirements
G. Facilitate quality assurance and utilization review
II. Elements of Good Clinical Documentation
A. Consider the purpose and context
1. Assessment, treatment planning, progress note, termination
2. Effects of context on patient presentation and information-sharing
B. Impact of state and federal laws and regulations, including HIPAA
C. Minimum data
D. How much/what data to include?
1. Balancing client care with legal and ethical requirements and risk
E. Recordkeeping in organizational settings
F. Multiple client records
G. Documentation in high-risk cases
1. Violence and threats of violence
2. Homicidal and suicidal ideation
3. Physical and sexual abuse
4. Criminal behavior
1. What should a termination summary include?
3. Right to refuse service
I. Maintaining awareness of potential readers
1. Attorneys, judges (subpoenas)
3. Team members
4. Other professionals (clinical, forensic uses)
5. Investigators and board members in the event of a complaint
J. Psychotherapy Notes
1. HIPAA definition
2. Awareness of state laws/regulations/case law
- Explain the purpose of clinical documentation
- Describe the content of good clinical documentation
- Describe the process of ethical decision-making in clinical documentation
- Discuss potential ethical and legal ramifications of clinical documentation decisions
American Psychological Association: https://www.apa.org/ethics/code
American Counseling Association: https://www.counseling.org/resources/aca-code-of-ethics.pdf
National Association of Social Workers:
The Center for Ethical Practice is approved by the American Psychological Center for Ethical Practice is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. The Center maintains responsibility for this program and its content.
The Center for Ethical Practice has been approved by National Board for Certified Counselors (NBCC) as an Approved Continuing Education Provider (ACEP No. 6768). The Center is solely responsible for all aspects of the programs. Programs that do not qualify for NBCC credit are clearly identified.
The Center for Ethical Practice (provider 1287), is approved as an ACE provider to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE provider approval period: 3/21/2021-3/21/2024. Social workers completing this course receive 3 ethics continuing education credits.
The Center for Ethical Practice
977 Seminole Trail, Charlottesville VA 22901