A social worker’s clinical records can be his/her best defense in malpractice litigation. A typical court case relies on the content or lack of content in the record to determine if malpractice has occurred. Stephanie Tracy, LCSW, knew that her records would be subpoenaed when she was sued for malpractice. She had been treating a couple in therapy over the past year. Not only was the couple divorcing, but one party was suing her for breaching confidentiality.
Ms. Tracy reviewed her records, just as her defense attorney had instructed, assembling the documentation of client visits, insurance reimbursement and clinical notes. During this process, she noticed that some sessions did not have a corresponding clinical note. She also noticed some minor errors in their notes regarding some test results. Ms. Tracy decided to correct these imperfections in her records by recopying the appropriate pages to include her revisions.
Since Ms. Tracy felt the revisions were minor, she didn’t highlight the changes. When she forwarded the records to her defense attorney with a note about her revisions, she was surprised to get a call from the attorney insisting that only a copy of the original records was acceptable.
Redacting records is a common enough occurrence. Therapists do make errors in charting or subsequently need to amend clinical notes based on new information or insights. The key to redacting records is openness about making the correction. Barbara Calfee, JD, LSW recommends that all errors are corrected as follows:
• Put a line through the error
• Put your initials near the correction
• Date the correction
• Mark "error" or "error in charting" by the correction.
Amending a record can be accomplish-ed with "addendum entries," which are notes that are out of sequence from the therapeutic session to which they refer. They are commonly used to note a change in diagnosis or new insights in the treatment process. Ms. Calfee recommends marking the entry with the date it is being recorded as well as the date of the event or session being discussed. A therapist should never recopy records unless her defense attorney specifically requests it.(Originally published 1994.)
Ms. Tracy was lucky that her revised notes did not go beyond her defense attorney. If the plaintiff’s attorney had discovered the unmarked redactions, all of Ms. Tracy’s records would have been suspect and her credibility badly damaged during trial. Instead of protecting her, Ms. Tracy’s records could have been used as evidence that she was negligent and trying to conceal it in her records.
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