||Documenting Psychotherapy: Essentials for Mental
||Mary E. Moline, George T. Williams, and Kenneth M. Austin
||Sage Publications, ©1998
2455 Teller Rd.
Thousand Oaks, CA 91320
Keeping accurate records that meet legal requirements and the ethical codes of the professions is so rare that we often advise attorneys there is always going to be something with which to impeach an expert witness in the way the records are kept. There is no other area where practitioners are as vulnerable to criticism, attack, and malpractice litigation.
This 189-page book is a much needed and invaluable resource both for keeping proper records and for litigation when acceptable records are not kept. For the mental health professional this is $20.00 that may well be the cheapest insurance policy ever purchased. Every year there are over 10,000 lawsuits against psychotherapists. Whether there have been good records kept may well determine the outcome of many of them. The importance of good records is also clear in dealing with any ethical complaints brought to regulatory boards or professional association ethics committees.
But the most significant reason for keeping good records is not avoiding litigation. It is that good records are a vital aid to a therapist in providing effective services to the patient or client. It is not possible for the unaided human mind to avoid the reconstructive nature of memory and keep track and process large amounts of information without error. This is why science is essentially defined by keeping systematic records to track whatever is counted.
The book has five parts. Each chapter starts with material on the topic of the chapter, summarizes it, and then gives relevant legal cases with brief descriptions of the thrust of the decisions. Each chapter also has questions proposed for study and reflection. A brief vignette then gives a stimulus to apply what has been learned and thought through. The
first four sections are the importance of record keeping, the content of clinical records for various modalities, documenting safety issues, and special areas such as records of treatment of minors, client access, and retaining records. The last section is a series of very helpful appendices giving legal citations, examples, forms for treatment plans, billing records, consent forms, and other procedures often overlooked.
This is an indispensable book for every clinician who wants to do a good job, and for all others who think clinicians have not done a good job.
Reviewed by Ralph Underwager, Institute for Psychological Therapies, Northfield, Minnesota.