ERIC Number: ED337719
Record Type: RIE
Publication Date: 1991
Documentation in Counseling Records. AACD Legal Series. Volume 2.
Mitchell, Robert W.
This monograph about accountability and communication in record keeping is intended for human services professionals. Eight terms are defined in an introductory glossary. The first section discusses the purpose of records. The next section discusses clarity in staff notes. Key points are offered for effective communication through staff notes. The next section focuses on the causes of ineffective communication and on increasing risk exposure. One of the most effective tools for avoiding litigation is utilizing clear communications, particularly for records. The next section analyzes a staff note, noting that a frequent problem is that entries are too short and vague. Learning to write a substantial note in a few sentences is important. Examples of the need for clarity and precision are the focus of the next section. The counselor's written words are the only record of a session with a client, and therefore need to be written accurately. The next section discusses ways of responding to an outside inquiry. Letters responding for outside requests for information demonstrate the counselor's professionalism and expertise. The essentials of the plan of care, care review, and staff notes are considered in the next section. This is followed by analysis of a group note. The next section evaluates a plan of care. Confidentiality and other legal issues are discussed in the next section. The final section provides answers to frequently asked questions. A summary, discussion questions, and references and suggested readings are included. (LLL)
Descriptors: Accountability, Case Records, Communication (Thought Transfer), Confidentiality, Counseling, Counselors, Documentation, Human Services, Legal Responsibility, Records Management, Writing Skills
American Association for Counseling and Development, 5999 Stevenson Avenue, Alexandria, VA 22304 (Order No. 72022: $11.95 each).
Publication Type: Guides - General
Education Level: N/A
Authoring Institution: American Association for Counseling and Development, Alexandria, VA.