The Use of Documentation in a Behavioral Health Setting
Introduction
The purpose of documentation in a behavioral health setting is:
- To meet ongoing patient needs (CMS, n.d.);
- To create appropriate communication between professionals;
- A required document by Federal and State laws to maintain records (Social Security Act, n.d.);
- To protect from challenges to furnished treatment, different types of penalties, including civil, administrative, criminal, and litigation (CMS, n.d.).
The primary diagnostic systems used in behavioral health
Major diagnostic manuals are the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders. Implemented in public health, clinical diagnosis, service provision, specific research applications, National Institute of Mental Health’s Research Domain Criteria, and Integration of basic behavioral and neuroscience research.
Examples of the implementation of the primary diagnostic systems
These methods are used for the diagnosis of many illnesses. The most identified finding for the race: are schizophrenia and psychotic affective disorders (Garb, 2017). The most spread result for gender: histrionic personality disorder and antisocial personality (Garb, 2017). The most widely replicated result for age: are organic impairment and depressive disorder, and antisocial personality disorder (Garb, 2017).
Ethical and Legal Standards that Guide Behavioral Health Documentation Standards
Confidentiality
Securing clients’ privacy and providing safety is a crucial priority of documentation (Sturm, 2012).
Disclosing record-keeping procedures
The rules identify the information of “the nature and extent of record-keeping procedures” as a violation of the ethics code (Ethics Code 3.10).
Maintenance and security
Practitioners are required to access a security plan that facilitates decent protection for papers or electronic records, avoids loss or damage, and establishes appropriate security standards by professionals (Sturm, 2012).
Retention of records
Professionals reviewing records should also recognize and identify clinical documents their type, be able to test results, and take proper decision-making (Sturm, 2012).
Differences between Electronic Health Records (EHR) and Electronic Medical Records (EMR)
EMR:
- A digital version of the patient’s chart;
- Contains the patient’s medical and treatment history;
- Stay in doctor’s office, does not get shared.
EHR:
- Records from multiple doctors;
- Long-term view;
- Includes: demographics, test results, medical history, history of present illness, and medications.
The Strengths of Having Client Records Available in a Database
Provide accurate, up-to-date information about the patient. Enable quick access for coordinated and efficient care. Securely share electronic information. Diagnose patients, reduce medical errors, and provide safer care.
The Limitations of Having Client Records Available in a Database
- Potential Privacy and Security Issues;
- Inaccurate Information;
- Frightening Patients Needlessly;
- Malpractice Liability Concerns.
References
Clark, L. A., Cuthbert, B., Lewis-Fernández, R., Narrow, W. E., & Reed, G.
M. (2017). Three approaches to understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental health’s research Domain CRITERIA (RDOC). Psychological Science in the Public Interest, 18(2), 72–145. Web.
Garb, N. (2017). Diagnostic classification systems are designed primarily to assist clinicians in determining which condition(s) apply to patients presenting with psychiatric disorder. Anxiety in Children and Adolescents with Autism Spectrum Disorder.
Healthcare, G. (n.d.). Gallagher healthcare :: Industry Insights Blog. Advantages and Disadvantages of Electronic Health Records. Web.
Medical Documentation for Behavioural Health Practitioners. CMS. (n.d.). Web.
Social Security Act (n.d.). State plans for medical assistance. Act §1902. Web.
Sturm, D. C. (2012). Record keeping for practitioners. Monitor on Psychology. Web.
What are the advantages of electronic health records? HealthIT.gov. (2019). Web.