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C H A P T E R 12

Evaluation and Accountability

Dr. Flournoy: Hello, Ms. Wicks?

Ms. Wicks: Yes.

Dr. Flournoy: I am Dr. Flournoy from Children and Youth Services.

Ms. Wicks: Hello.

Dr. Flournoy: The Ramerez family has been referred to our service, and I understand that you have been working with Maria, here at school. I have requested that your counseling records be subpoenaed, and I simply wanted to let you know ahead of time, so that you could begin to get them in order.

C ounseling records? Subpoenas? For some mental health practitioners the idea of maintaining records may be an anathema to the nature of the helping process. Further, the invitation to disclose these records

as a result of a simple request, subpoena, or court order can arouse debilitat- ing anxiety.

The need and ethical responsibility of keeping and maintaining records along with the inherent conflict that may exist when disclosure of these records is requested serves as the focus for the current chapter.

Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37.

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● OBJECTIVES

The chapter will introduce you to the importance of maintaining records as both a measure of professional accountability and an essential step toward demonstrating ethical practice. After reading this chapter you should be able to do the following:

• Describe the benefits of utilizing a system of evaluation within one’s practice

• Define the terms formative and summative evaluation • Describe one approach to measuring outcome and goal achievement • Identify the minimal records necessary for demonstrating competent,

ethical practice

While it is true that no one professional can guarantee success in each and every encounter, the ethical practitioner will monitor services and adjust as required. Such a monitoring—or evaluation—be it through the informal collection of data or more formal forms, can offer direction and serve to demonstrate accountability. However, for some helpers, the concept of evaluation may be viewed as superfluous or tangential to the primary function of helping. While there is abundant evidence of the need for all mental health professionals to be able to demonstrate client progress and treatment effectiveness to the stakeholders they serve (Astra- movich & Coker, 2007), the use of a well-developed system of practice assessment simply makes good practical sense. Such a system of assess- ment and accountability not only highlights the reality of the terminal nature of the professional relationship and provides a reference point for knowing when the process has achieved its desired end (i.e., summative evaluation), but it also provides markers to guide the process (i.e., forma- tive evaluation) and thus ensure it remains on target for goal achievement. When viewed through the lens of accountability, to the client and the profession, an eval uation system becomes an essential ethical practice (see Table 12.1).

● MONITORING AND EVALUATING INTERVENTION EFFECTS

Evaluation is often thought of as something that is done at the end of a process. As suggested above, for evaluation to be prescriptive it needs to be ongoing and formative as well as summative in form.

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Table 12.1 Ethical Positions on Record Keeping

Professional Organization Position on Record Keeping

American Counseling Association (2014)

B.6. Records and documentation

a. Creating and maintaining records and documentation

Counselors create and maintain records and documentation necessary for rendering professional services.

b. Respect for confidentiality

Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification.

American Psychological Association (2010)

6.01. Documentation of professional and scientific work and maintenance of records

Psychologists create, and to the extent the records are under control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analysis, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law.

6.04. Maintenance, dissemination, and disposal of confidential records of professional and scientific work

a. Psychologists maintain confidentiality in creating, storing, accessing, transferring, and disposing of records under their control, whether these are written, automated, or in any other medium.

b. If confidential information concerning recipients of psychological services is entered into databases or systems of records available to persons whose access has not be consented to by the recipient, psychologists use coding or other techniques to avoid the inclusion of personal identifiers.

c. Psychologists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists’ withdrawal from positions or practice.

American Association for Marriage and Family Therapy (2015)

2.5.

Marriage and family therapists store, safeguard, and dispose of client records in ways that maintain confidentiality and in accord with applicable laws and professional standards.

(Continued)

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Professional Organization Position on Record Keeping

National Association of Social Workers (2008)

3.04.

a. Social workers should take reasonable steps to ensure that documentation in records are accurate and reflective of services provided.

b. Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of service provided to clients in the future.

c. Social workers’ documentation should protect clients’ privacy to the extent that is possible and appropriate and should include only information that is directly relevant to the delivery of services.

d. Social workers should store records following the termination of services to ensure reasonable future access. Records should be maintained for the number of years required by state statues or relevant contracts.

Table 12.1 (Continued)

Formative Evaluation

Formative evaluation is evaluation that occurs as an ongoing process throughout the helping encounter. It is the gathering of feedback and data used to expedite decision-making about the current process and the upcom- ing steps and procedures to be employed. It pro vides data that give form to the ongoing process. The means of collecting formative data can range in degree of formality. For example, a practitioner may choose to use a structured survey or questionnaire at various points in the helping encounter. Or more infor- mally, the practitioner may simply set time aside to solicit feedback from the client about his or her experience in the relationship with the helper and the pro cedures employed up to this par ticular point (see Case Illustration 12.1).

Case Illustration 12.1

Formative Evaluation

Dr. Brown: First let me tell you how much I appreciate your open- ness and willingness to share with me some of your concerns about your social relationships and your desire

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Chapter 12. Evaluation and Accountability–●–301

to become more assertive in these. I feel very comfort- able working with you and feel that the things we have talked about in this first session have really helped us to clarify your goal and even begin developing a strategy for getting there. I think it may be helpful if we took a moment to share our perceptions on this session as a way of making future sessions more productive. I would be very inter ested in receiving your feedback about our session today.

Jim: To be honest, I was very nervous when I made the appointment. However, I am really surprised how much I shared. I really feel like I can trust you. I feel very comfortable speaking with you, and that is not my style, usually.

Dr. Brown: Well, that is very nice to hear, and I know from what you told me that you tend to be a private person. Jim, as you are aware, we will probably want to talk more about your fam- ily background and previous relationships as our sessions go on. How do you feel about that? (Dr. Brown checks Jim’s understanding of the help ing process.)

Jim: I know that probably needs to be done. It makes me a little anxious, but as I said, I do feel comfortable with you and trust you, especially how you explained the idea of confidentiality, I just may need to go slow.

Dr. Brown: That’s good feedback for me. The pace of the sessions really will be the one that feels right for you. So if we need to go slow, we will. If you want to dive into something and it seems right to me, we will. I think as long as we continue to “process” how we are doing, we can make sure we stay on track at a pace which is both productive and comfortable. (Dr. Brown checks Jim’s comfort level and takes direction.)

Jim: Yeah, me too.

Dr. Brown: So, while overall you are hoping to get some help with developing assertiveness skills, our immediate goal is for you to take notes on two incidents: one in which you felt you were assertive and one in which you felt

(Continued)

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For this evaluation to truly form and give shape to the decision-making pro- cesses, it should begin with the first session. As evident in Case Illustration 12.1, the helper engaged in for mative evaluation within the first session. The approach taken by this helper provided insight into the client’s level of comfort with the interaction and his ability to engage col laboratively in the helping process. This evaluation also served as a check on the accuracy of the helper’s understanding regarding the desired goals and outcome for the helping process. The use of such a formative evaluation not only provides for helper accountabil ity but also provides the data for monitoring and increasing efficacy of treatment.

Summative Evaluation

Summative evaluation is the type of evaluation most typically thought of when considering goal or outcome assessment. The specific purpose of summative evaluation is to demonstrate that the action plan has reached its original objective. Summative evaluation provides the helper and the client data to determine (a) if the original goals were achieved, (b) the factors that contributed to this goal attainment, and (c) maybe even the value of this strategy versus some alternative. The articulation of clear treatment goals and the employment of summative evaluation strategies serve as invaluable sources for demonstrating treatment efficacy and helper accountability.

The presence of clearly articulated goals or outcomes is essential for both formative and summative forms of evaluation. Without a clear, shared vision of where the helping process is going, it will be hard to know if it is on track or even if it has arrived. Thus, the establishment of treatment goals and objec- tives, the identification of outcome measures, and the maintenance of appro- priate responsible records serve as keystones to ethical and efficient practice.

Setting Treatment Goals and Objectives

While it may seem obvious that the counseling relationship and process is neither totally open ended nor aimless, as a professional encounter, our helping

very unassertive. Are these the goals we agreed on? (Dr. Brown checks agreement on goals.)

Jim: Yes, that’s exactly what I want to do . . . get more assertive! And I like the idea of doing some “research work” for our next session.

(Continued)

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is both intentional and directional. To be effective, it is essential that the helper, along with the client, identifies and clarifies client needs and desired goals. Research (e.g., Seijts, Latham, Tasa, & Latham, 2004) has demonstrated that the articulation of goals is essential to the problem-solving process. However, to be effective, these goals cannot be vague, overly generalized, or unrealistic. As such, it is suggested that the effective, ethical practitioner will help the client to set goals that are specific, measureable, attainable, relevant, and time bound (Parsons & Zhang, 2014). Such goals may be identified with the acronym SMART goals. Taking these into consideration for one’s own practice, the ques- tions posed in Table 12.2 will be helpful in the development of these goals.

Table 12.2 Developing SMART Goals

Goal Characteristics Questions to Guide Goal Setting

Specific Does the goal outline exactly what you are trying to achieve?

Measurable How will you know if progress is being made?

How will others know if progress is being made?

Is the progress quantifiable?

Attainable What resources do you need to achieve this goal?

Can the goal be achieved independently?

Is the goal too big? If so, can the goal be broken down into smaller SMART goals?

What factors or forces exist that could interfere with the achievement of the goal?

What is the plan to remove or navigate these forces?

Relevant How important to you is this goal?

What are the positive consequences of achieving this goal?

How will achieving this goal affect your personal and professional life?

Time Bound Have you set a target date?

Can you establish benchmarks along the way to use as evidence of progress?

Is the timeline reasonable? Flexible?

Source: Adapted from Zhang & Parsons (2016). Field experience: Transitioning from student to professional. SAGE Publications, Thousand Oaks: CA.

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Measuring Outcome and Goal Achievement

The selection of appropriate outcome measures is far from easy. Clinicians recognize that the helping process, when effective, can reveal itself in many ways—even beyond the achievement of the terminal goal. For example, while attempting to help a client cope with his social anxiety it may not be unusual to find that the client exits the relationship with a better sense of his own vocational calling or insight into his current relationships or even a desire to pursue additional growth-oriented counseling. Using more than one outcome and outcome measure increases the probability of accurately depicting the entirety of the experience. At the most fundamental level, the prac titioner can assume that one outcome reflects the nature of the presenting concern. For example, if a clinician is interested in ameliorating a presenting complaint, the nature of that complaint (e.g., test anxiety, marital dissatisfaction, depression, etc.) provides direction to the outcomes desired. After targeting the general area in which the helper expects to demonstrate impact (i.e., reduce test anxiety, increase achievement level, etc.), that partic- ular area needs to be clearly and concretely defined. It is important to realize that while there will be a primary focus for the assessing outcome (e.g., reduce the amount of client depression or increase student attention, etc.), these tar- gets may be manifested in a number of different ways and occur within a unique context. The more perspectives we take on the outcome and the more mea- sures we employ, the greater the chance we have of under standing the nature and depth of impact our practice may have produced. Consider the approach taken by the helper illustrated in the following case (Case Illustration 12.2).

Case Illustration 12.2

Assessing Outcomes of Treatment With Depressed Client

Alicia came to therapy because of a “constant” feeling of sadness and an inability to get moti vated about anything in her life. At the initial meeting with Alicia, Dr. Warrick attempted to identify the various ways in which her feelings of sadness were experienced and were impact ing her life.

Dr. Warrick: Alicia, you have mentioned that you are not “doing anything” and you can’t get motivated. Could you tell me more about that?

Alicia: Well, I have a lot of school work that should be done, and each time I sit down to do it I think, why bother,

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nothing is going to come out, and then I walk away from the computer and get something to eat or go to bed.

Dr. Warrick: So it seems that you not only feel sad, at times, but you also have this belief that “nothing is going to work”?

Alicia: That’s right! And it is not just with school stuff. If I get a call from a friend I typically go out with, I think, why bother going out, it is not going to help. And I stay home.

Dr. Warrick: So one of the things that we may watch as we work together isn’t just your feelings of sadness but also the frequency of this, why bother, it’s hopeless thinking?

Alicia: I don’t want to feel sad anymore, but I also understand what you mean about the thinking.

Dr. Warrick: You also seem to suggest that when you are feeling this way, you avoid your friends and avoid engaging in activities (like school work)?

Alicia: Yeah, I have not seen my friends in weeks. I’m sure they are annoyed. And I don’t even do housework anymore. My place is a mess.

Dr. Warrick: Well, Alicia, I appreciate how open you have been with me today, and I truly feel we have taken a good step toward helping you to feel and behave the way you want to. As we continue working together, we will not only keep our eyes on your feelings of sadness with the intent of gaining some relief, but we will see if there is an increase in the frequency with which you go out with your friends or do house chores and school work. Further, we will hopefully also see a change in your thinking. Rather than thinking why bother thoughts, we will see more productive thoughts. How does that sound?

Alicia: It sounds like a lot and I’m not sure that we can do this. Wow, there is that why bother thought again!

(Continued)

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But, if I would start feeling and thinking and acting dif ferently, then I would not need to be here.

Dr. Warrick: That’s good! I like the way you already attacked that thought of yours!

(Continued)

While most individuals recognize depression to be a mood, an affect, or a feeling, depression also manifests itself in a person’s behavior, thought processes, and interpersonal interactions. A helper, like Dr. Warrick (see Case Illustration 12.2), who may be attempting to assess the effec- tiveness of a particular medication or treatment approach on depres- sion, should assess changes not only in the client’s mood but also in the client’s behavior (e.g., doing school work), thought processes (e.g., hav- ing less frequent thoughts of suicide or thoughts of why bother), and interpersonal interactions (e.g., beginning to reengage with fam ily and friends), along with gathering information about how the client feels about these changes.

Table 12.3 provides one useful way for conceptualizing the various domains in which interventions may impact the client. It is useful to con- sider gathering data in many, if not all, of these domains in an attempt to accurately evaluate the impact of practice decisions. The listing presented is an adaptation of the work of Arnold Lazarus (1989). The essence of this model is the belief that a person’s functioning or dysfunctioning is mani- fested along seven modalities: behavior, affect, sensation, images, cognition, interpersonal relationships, and biology/physiology. Lazarus represented these seven domains with the acronym BASIC ID. Using each of these com- ponents as a reference point, the helper can conceptu alize the impacts of his or her practice more broadly.

Table 12.3 presents three dimensions for consideration when identifying outcomes to action research. First, modality refers to the specific arena in which this construct may be manifested (i.e., BASIC ID). The second dimen- sion, manifestation, is the place where the practitioner identifies the manner or form in which this particular target of the investigation appears. The final column, data collection techniques, identifies the types of techniques that can be useful when assessing that domain. It should be noted that while a specific method of data collection has been identified in Table 12.3, other methods may work as well.

Exercise 12.1 provides an opportunity to employ to this approach with a problem of your choosing.

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Table 12.3 Classification Scheme for Outcome Measures: Using an Example of a Client

Experiencing Anxiety in Social Settings

Modality Manifestation Sample Methods of Data Collection

Behavior Withdraws from social contact Observation

Affect Anxious Survey (anxiety checklist)

Sensation Muscle tension Self-report (journal)

Imagery Dreams about being abandoned Self-report (journal)

Cognition Believes he has no right to say no Assertiveness questionnaire

Interpersonal Withdraws and fails to maintain eye contact

Observation, interview peers

Drugs/Biology Stomach upset/blood pressure high Self-report and blood pressure recordings

Exercise 12.1

Identifying Personal Outcomes

Directions: Below are a number of general statements about personal improvement and growth. Select one that may be of interest to you and using the table below, identify the various manifestations of this goal achievement along with techniques for assessment.

● Become a better student

● Become more social

● Become more spiritual

● Improve general health

Modality Definition Sample Methods of Data Collection

Behavior

Affect

(Continued)

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Modality Definition Sample Methods of Data Collection

Sensations

Imagery

Cognition

Interpersonal

Drugs

(Continued)

Record Keeping

Record keeping is important not just to document service but also to guide and direct the practitioner in his or her practice decisions. Accurate, complete records can, for example, allow a practitioner to review the thera- peutic process and thus foster self-monitoring on the part of the practitioner. Thus, implicit within the discussion of evaluation and outcome measure- ment is the understanding that data will be collected and recorded for later analy sis. These data can be of various forms, including test scores, clinician observations, and notations. In whatever form they are, these data constitute a client’s record and must be handled with sensitivity.

Maintaining thorough records and clinical notes is essential to the plan- ning and mon itoring of services as well as to providing data, should the interaction ever be questioned as in the case of a lawsuit. Keeping good and accurate records provides a strong foundation for counselors in the event of claims regarding legal issues and ethics violations (Mitchell, 2007). Thus, even with concern about possible requirements to disclose, experiences of inconvenience, or a practitioner’s belief in the power of his or her memory, the ethical practitioner will collect and maintain useful professional records. In fact, all of the professional organizations (see Table 12.1) call for the ethi- cal collection, maintenance, and dissemination of client information.

Nature and Extent of Records

Records should document the nature, delivery, and progress of services provided. Addi tional information may be required by state statute and/or

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contract, as when services are pro vided as part of a managed care organization. While the specifics of what may be required as part of a client’s record varies from state to state, generally it is important to maintain a legible record that includes at a minimum the following: identifying data; dates of services; types of ser vices; fees; any assessment, plan for intervention, consultation, and/or sum- mary reports as may be appropriate; and any release of information obtained. One example of the types of records one should maintain was developed by the Committee on Professional Practice and Standards of the APA. While the model is somewhat dated it remains a useful guide for practitioners. This com- mittee adopted a set of guidelines (see Canter, Bennett, Jones, & Nagy, 1994), which suggests that at a minimum records should contain the following:

• Intake sheet, including client identifying information • Documentation of a mental status assessment • Signed informed consent • Treatment plans • Psychological tests • Documentation of referrals • Types of services provided • Appointment dates and times • Release of information • Discharge summary

While the above provides some minimal guidelines for identifying the nature and type of records to be collected and maintained, the specific form of each of the above or the nature and content and style of clinical notes and records will be determined by the spe cific regulations of the setting in which the services are provided, state laws, or helper preferences (see Exercise 12.2).

Exercise 12.2

Nature of Records to be Kept

Directions: Using the questions listed below, interview two profes- sional helpers in each of the following professions:

● Private practitioner

● School counselor

● Criminal justice worker/counselor (Continued)

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Regardless of the types of data collected, clarity and utility should guide the process. The notes are meant to assist in the treatment (utility), and since records belong to the client and copies could be requested, they should be clearly written in a manner that is honest and non-demeaning.

Storage and Access

The collection and maintenance of such sensitive information can con- flict with a client’s right to personal privacy if not handled professionally and ethically. For example, the American Psychological Association’s ethical code (2010), Principle 6.02 (a) states, “Psychologists maintain confidentiality in creating, storing, accessing, transfer ring and disposing of records under their control, whether these are written, automated, or in any other medium.”

There is, however, no one set of standards that concretely and uni- versally applies across professions and settings. It is incumbent for each professional to understand the eth ical principles articulated within his or her profession. In addition to these standards, the practitioner needs to be aware of the legal statutes and practice principles governing the acquisition, storage, and maintenance of records in his or her own particular setting. For exam ple, practitioners working within a school setting that receives federal

● Drug and alcohol counselor

● Marriage therapist

Ask each helper if he or she keeps client files and if not, why not. If yes, ask him or her

● What type of information do you keep in your files?

● How long do you maintain your files?

● Does your client have access to these files?

● Have you had your records subpoenaed? If so, what was your response?

Compare and contrast the helpers’ responses. Was there commonality within the specific helping profession? What similarities or differences existed across professional groups?

(Continued)

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funding will be gov erned by the Family Educational Rights and Privacy Act (FERPA) (U.S. Department of Education. 2015). This act provides rights of access to educational records to students and their parents and defines educational record as any record kept by employees of the educational institution. Since broad access of records is not required of practitioners working within a non-federally funded setting, it is clear that the decisions regarding the nature of records collected and the forms of storage can vary setting to setting.

In what is now a significant event in the history of educational record keeping, the Russell Sage Foundation convened a conference in 1969 of representatives from educational and legal institutions as well as experts in related fields to address the issue of col lecting, maintaining, and disseminating records within the schools. The members concluded that “current practices of schools and school personnel relating to the collection, maintenance, use and dissemination of information about pupils threaten a desirable bal ance between the individual’s right to privacy and the school’s stated ‘need to know’” (Rus sell Sage Foundation, 1970). The outcome of this conference was the production of a proposed set of guidelines that, while targeted to pupil records, has value for all practition ers, regardless of the setting and the popu- lation with whom they work. A number of points gleaned from the historic conference are presented in and serve as a reference point for Exercise 12.3.

Table 12.4 Summary of Russell Sage Conference

Collection of Data Consent

No information should be collected without prior informed consent.

The client should be informed as fully as possible, consonant with the practitioner’s professional responsibility and the capacity of the client to understand.

Even when data is collected under conditions of anonymity, the obligation to obtain consent remains.

Maintenance of Data

Levels: Category A Data included here reflect the minimum personal data necessary (e.g., name, address, date of birth, academic background, etc.).

For schools, these data should be maintained in perpetuity.

(Continued)

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Collection of Data Consent

No information should be collected without prior informed consent.

Category B Data are of clear importance but not absolutely necessary for helping the client or protecting others over time (e.g., scores on standardized testing, family background data, observations and rating scales).

These data (in regard to school settings) should be eliminated as unnecessary at periodic intervals (e.g., transition points, such as moving from elementary to junior high).

Category C This is useful information needed for the immediate present (e.g., legal or clinical findings).

Data should be reviewed at least once a year (in school settings) and destroyed as soon as their usefulness is ended. If usefulness continues and validity of information has been verified, they may be transferred to Category B.

Confidential, personal files

Any and all data that are considered personal property of the professional should be guarded by the rules given above and dictated by professional ethics, terms of employment, and any special agreements made between the professional and the client.

Dissemination Releasing without consent

In school setting, category A and B data may be released to other school officials including teachers who have a legitimate educational interest in pupil records.

With consent/ judicial order

School may not divulge any information to anyone outside of the legitimate school personnel without written consent or compliance with judicial order.

Non-release Under no conditions, except court order, should school release information in Category C.

Table 12.4 (Continued)

Source: Adapted from Guidelines for the Collection, Maintenance and Dissemination of Pupil Records. Report of a Conference on the Ethical and Legal Aspects of School Record Keeping (1969). © Russell Sage Foundation, 112 East 64th Street, New York, NY 10065. Reprinted with Permission.

Database and Computer Storage

The issue of storage and access takes on special significance when considered within the advances of this technological era and the use of

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Exercise 12.3

Assessing School Record Keeping

Directions:

Step 1: Contact your high school or a local high school. Inquire what their policy is regarding the gathering, maintenance, access, and disposal of the following types of records:

● Student attendance

● Student course grades

● Student discipline record

● Student health records

● Student standardized test scores

● Student counseling records (if any)

● Student Individualized Education Plan (IEPs) or specialized academic program plans

● Teacher, counselor, administrator anecdotal notes on students

Step 2: Using the category breakdown listed in Table 12.4 (Russell Sage Foundation, 1970), evaluate the degree to which this school is following the Russell Sage guidelines.

computers for database storage. For exam ple, the American Psychological Association’s ethical code describes the situation: “If confidential informa- tion concerning recipients of psychological services is to be entered into databases or systems of records available to persons whose access has not been consented to by the recipient, psychologists use coding or other tech- niques to avoid the inclusion of personal identifiers” (APA, 2010, 6.02 [b]).

RECENT LEGAL DECISIONS ●

One area of professional practice that has recently been impacted by court decisions is in regard to a client’s right to access psychiatric records. The federal Freedom of Information Act of 1966 and various state patients’ rights laws often specify client right to access cer tain personal records. While men- tal health records have previously been exempted from this policy, the trend appears to be reversing in favor of client access.

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For example, it was initially successfully argued that such free access could result in harm to a client, that sharing technical information with clients who are not equipped to understand or deal with this informa- tion may prove counterproductive and/or harmful. This argument found support in the case of Godkin v. Miller (1975). Janet Godkin had been a voluntary patient at three different New York hospitals. Later, she and her husband decided to write about the experience and requested access to her records. Her requests were denied. In her lawsuit against the New York State Commissioner of Mental Hygiene and the direc tors of the hos- pital, the court ruled that the refusal was warranted in light of the fact that the hospitals stated a preference to release the information to another professional. There are a number of points in the process of record acqui- sition, storage, maintenance, access, and dis position in which a practitio- ner may be confronted with ethical and or legal questions. However, the courts have not provided a clear directive covering all of these aspects. Without clear legal direction, it is important for practitioners to adhere to commonly held and customary practices and those reflecting their specific codes of ethics. As such it is important to keep the following in mind when keeping records:

1. Ensure that all records and documentation be kept in secure loca- tions where unauthorized access is denied (e.g., ACA, 2014, Principle B.6.b).

2. Write notes in nontechnical, clear, and objective statements with behavioral descriptions. Subjective or evaluative statements involving professional judgments should be designated as such and written in a separate section clearly set aside from factual content. Many practi- tioners use the S.O.A.P. (subjective, objective, assessment, and plan) format for note taking (Cameron, & Turtle-Song, 2002).

3. All client records should be written with the understanding that they might be seen by the client, a court, or some other authorized per- son, who may refer to the notes for continuity of care (e.g., see APA, 2010, Principle 6.01).

4. Realizing the purposes for which we maintain records, only infor- mation that is necessary for documenting that which was done and directing that which should be or will be done, should be recorded. The American Counseling Association, for example, is clear in stat- ing that its members “include sufficient and timely documentation to facilitate the delivery and continuity of services” and “ensure that documentation accurately reflects client progress and services pro- vided” (ACA, 2014, Principle A1.b).

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CONCLUDING CASE ILLUSTRATION ●

The scenario that opened this chapter highlighted the importance of record keeping and the potential that such records may be requested. As we con- tinue the scene, however, we will see that it also raises a number of issues regarding (a) the types of information one collects; (b) the way that records are maintained, and (c) the questions of access to records.

Dr. Flournoy: Hello, Ms. Wicks?

Ms. Wicks: Yes?

Dr. Flournoy: I am Dr. Flournoy from Children and Youth Services.

Ms. Wicks: Hello.

Dr. Flournoy: The Ramerez family has been referred to our service, and I under stand that you have been working with Maria, here at school. I have requested that your counseling records be sub- poenaed, and I simply wanted to let you know ahead of time, so that you could begin to get them in order.

Ms. Wicks: I appreciate your notification. Even though we utilize computer- ized intake forms, inventories, and counseling notes, it is always nice to have some lead time to get them together. As I am sure you are aware, I will need a copy of the Release of Information and I would like one from Maria, in addition to her parents.

Dr. Flournoy: I understand that you would like a release, and actually I brought copies of both a parent release and the client’s signed release. You can keep them for your records. You mentioned that you have intake forms, inventories, and client notes with computer access.

Ms. Wicks: Yes.

Dr. Flournoy: Well, I’m going to ask for all the notes, including your profes- sional observations and anecdotal notes.

Ms. Wicks: Well, Dr. Flournoy, the school’s policy is that counselor records include

• Intake sheet, including client identifying information • Signed informed consent • Documentation of referrals • Types of services provided

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• Standardized test scores and/or inventories employed • Appointment record • Release of information • Summary of contact

So I will be happy to provide these to you.

Dr. Flournoy: Thank you. But I know as a counselor you probably kept personal notes. I would like to see those as well.

Ms. Wicks: The notes that we have are those identified by school policy. I’ve already listed those and I will be glad to provide them. But first, I do want to speak with Maria, and even though she signed the release, I would like her to know exactly what we will be releasing.

Reflections

1. What do you think about Ms. Wicks’s request for a release of infor- mation from both the parents and Maria? Was it legally required? Ethically required?

2. Ms. Wicks outlined the type of information that the school directed counselors to maintain. How adequate do these records appear to be? Is there anything you feel is missing?

3. What concerns would you have with having this data in computer storage?

4. What is your reaction to Ms. Wicks’s response in regard to personal, anecdotal notes?

5. Ms. Wicks noted that she wanted to explain to Maria the types of material to be released. Was that necessary? Required? What are your feelings regarding that decision?

● COOPERATIVE LEARNING EXERCISE

As with all of the previous cooperative learning exercises, the current exer- cise is designed to help you personalize the material and begin to move your understanding to professional practice. Working with a colleague and/or

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classmate, identify the types of client informa tion that you feel are needed in the course of your professional practice and that will be retained within a client record. Next, complete the following:

• Design samples of the specific forms or data collection tools you will employ.

• Contact three individuals currently working in the area of professional practice that you envision doing and request copies of their data col- lection tools and instruments.

• Finally, contact your state association and inquire about the length of time you will be responsible for maintaining these records.

SUMMARY ●

• Evaluation of the helping process needs to be ongoing and formative as well as sum mative in form. Formative evaluation is evaluation that occurs as an ongoing process throughout the helping encounter. Sum- mative evaluation is the type of evaluation most typically thought of when considering goal or outcome assessment.

• Because of the potential to influence the client and the client’s abil- ity to formulate his or her own goals and objectives, it is important for the practitioner to be sure to engage the client in terminal goal formulation.

• When articulating treatment goals, the more perspectives we take on the outcome and the more measures we employ, the greater the chance we have of understanding the nature and depth of impact our practice may have produced.

• Record keeping is important not just as a documentation of service but also to guide and direct the practitioner in his or her practice decisions.

• Maintaining thorough records and clinical notes is essential to the planning and monitoring of services as well as to providing data should the interaction ever be questioned, as in the case of a lawsuit.

• Records should document the nature, delivery, and progress of ser- vices provided. The collection and main tenance of such sensitive information can conflict with a client’s right to personal privacy if not handled professionally and ethically.

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● ADDITIONAL RESOURCES

American Psychological Association. (2007). Record keeping guidelines. American Psychologist, 62(9), 993–1004. Christiansen, R. (2012). Zig zag principle: The goal setting strategy that will revo-

lutionize your business and life. New York, NY: McGraw-Hill. Hatch, T. (2014). The use of data in school counseling: Hatching results for stu-

dents, programs, and the profession. Thousand Oaks, CA: Corwin. Luepker, E. T. (2012). Record keeping in psychotherapy and counseling: Protecting confidentiality and the professional relationship. New York, NY: Taylor

& Francis.

Wed-Based

Johnson, V. (2010, February 16). Jim Rohn setting goals part 1 [Video file]. Retrieved from www.youtube.com/watch?v=YuObJcgfSQA

Stone, C. (2013, July 1). FERPA: The ever-changing federal statue. ASCA school- counselor. Retrieved from http://www.schoolcounselor.org/magazine/blogs/ july-august-2013/ferpa-the-ever-changing-federal-statute-(1)

Wehrman, J. D., Williams, R., Field, J., & Schroeder, S. D. (2010). Accountability through documentation: What are best practices for school counselors? Journal of School Counseling, 8(38), 1–23.

● IMPORTANT TERMS

accountability modality

data collection techniques outcome measures

evaluation record keeping

Family Educational Russell Sage guidelines

and Privacy Act (FERPA) summative

formative terminal goal

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REFERENCES ●

American Association for Marriage and Family Therapy. (2015). Code of ethics. Retrieved from https://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/ Code_of_Ethics.aspx

American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author.

American Psychological Association. (2010). American Psychological Association’s ethical principles of psychologists and code of conduct. Retrieved from http:// www.apa.org/ethics/code/principles.pdf

Astramovich, R. L., & Coker, J. K. (2007). Program evaluation: The accountability bridge model for counselors. Journal of Counseling & Development, 85(2), 162–172.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80, 286–292.

Canter, M. B., Bennett, B. E., Jones, S. E., & Nagy, T. F. (1994). Ethics for psychologists: A commentary on the APA ethics code. Washington, DC: American Psychologi- cal Association.

Godkin v. Miller, 379 F. Supp. 859 (ED N.Y. 1974). Aff’d. 514 F 2d 123 (2d Cir. 1975). Lazarus, A. (1989). The practice of multimodal therapy (2nd ed). Baltimore: John

Hopkins University Press. Mitchell, R. W. (2007). Documentation in counseling records: An overview of ethi-

cal, legal, and clinical issues (3rd ed.). Alexandria, VA: American Counseling Association.

National Association of Social Workers (2008). Code of ethics of the National Asso- ciation of Social Workers. Retrieved from https://www.socialworkers.org/ pubs/code/code.asp

Parsons, R. D., & Zhang, N. (2014). Becoming a skilled counselor. Thousand Oaks, CA: Sage.

Russell Sage Foundation. (1970). Guidelines for the collection maintenance and dissemination of pupil records. Hartford, CN: Russell Sage Foundation.

Seijts, G. H., Latham, G. P., Tasa, K., & Latham, B. W. (2004). Goal setting and goal orientation: An integration of two different yet related literatures. Academy of Management Journal, 47, 227–239.

U.S. Department of Education. (2015). Family Educational Rights and Privacy Act (FERPA). Retrieved from http://www2.ed.gov/policy/gen/guid/fpco/ferpa/ index.html

Zhang, N., & Parsons, R. D. (2015). Field experience: Transitioning from student to professional. Thousand Oaks, CA: Sage.

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