By Ellen T. Luepker
Record conserving in Psychotherapy and Counseling offers an important framework for figuring out checklist protecting inside of felony, moral, supervisory, and scientific contexts. Compelling case examples determine dilemmas and techniques in retaining confidentiality. greater than an easy reference booklet, this article introduces the idea that of utilizing files as healing instruments to bolster the healing courting and facilitate medical supervision. Appendices and an accompanying CD provide pattern types. A reader-friendly variety makes this new version applicable for undergraduate and graduate scholars. New fabric on digital documents, the influence of digital conversation, and practitioners’ stories with imposing the medical insurance Portability and responsibility Act carry this booklet modern. all people from scholars to professional practitioners will proceed to depend upon it for shielding themselves, their sufferers, and their trainees.
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Additional info for Record Keeping in Psychotherapy and Counseling: Protecting Confidentiality and the Professional Relationship
For example, patients with borderline person ality disorder and history of victimization frequently elicit strong feelings in therapists, such as rescue fantasies, “splitting” from colleagues, or temptations to bend usual procedures, such as not billing for missed appointments (Gabbard & Wilkinson, 1994; Luepker, 1989). We are responsible for being aware of and properly managing such feelings in order to provide adequate treatment. Documentation of countertransference impressions in the official record, however, does not contribute to the purpose or quality of the record and therefore should be omitted.
One of the most frequent consultation requests I have received relates to demands therapists receive from insurance companies and attorneys for confidential patient information. Therapists have also described the disruption and anxiety they have felt when process servers have entered their waiting rooms with subpoenas or court orders. Many therapists have become so alarmed and confused by these unexpected events that they temporarily lose their clinical judgment and struggle with how to respond in the best interest of their patients and themselves.
The information in this section helps us further clarify what clinical intervention is necessary. Descriptions of our clients in this section include but aren’t limited to the following: • physical characteristics: body build, hair color, type of clothing, grooming, facial expression; • appropriateness of appearance to the situation; • mental status: affect, speech, mood, thought content, judgment, insight, memory, impulse control, attention, focus, concentration, and orientation to person, place, and time; • observations at various junctures of the interview.
Record Keeping in Psychotherapy and Counseling: Protecting Confidentiality and the Professional Relationship by Ellen T. Luepker