Thorough record keeping: A good defense in a litigious era.

Soisson, Ellen L.; VandeCreek, Leon; Knapp, Samuel

doi:10.1037/0735-7028.18.5.498

Cited by 28 publications

(32 citation statements)

References 9 publications

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“…T h e record can document the decision-making process, course of treatment, and patient's response to treatment. This should also include information about any instructions the therapist may have given the patient and evidence of the patient's cooperation with or resistance toward the treatment plan (Soisson et al, 1987). For each major therapeutic decision, the therapist should document what was done, why it was done, what other alternatives were considered, why one option was chosen over others (e.g., medications, hospitalization), and a brief evaluation of the risks and benefits involved in the chosen treatment plan.…”

Section: General Recommendationsmentioning

confidence: 99%

“…Every contact a therapist has with a patient, whether in person or over the telephone, should be recorded in the patient's record (Soisson, VandeCreek, & Knapp, 1987). This includes documenting any emergency meetings or phone calls the therapist may have with the patient, the patient's family members, or professional colleagues or supervisors.…”

Section: General Recommendationsmentioning

confidence: 99%

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Treatment of suicidal patients: A risk‐benefit analysis

Overholser

1995

Behavioral Sci & The Law

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A therapist may be held liable when a patient commits suicide if previous suicidal tendencies were observed but reasonable precautions were not taken. In order to reduce liability and enhance treatment effectiveness, therapeutic decisions can be critiqued by estimating the risks and benefits associated with different courses of action. An evaluation of risks and benefits can be used to guide decisions regarding assessment, hospitalization, medications, and discharge from the hospital. A risk-benefit analysis can help therapists utilize a broad range of treatment options while allowing patients the maximum degree of autonomy. Additionally, all aspects of treatment should be well documented, including information about the specific course of action chosen, other treatment options considered, and the therapeutic rationale for deciding which treatment plan was best suited to the patient's needs.

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Section: General Recommendationsmentioning

confidence: 99%

Section: General Recommendationsmentioning

confidence: 99%

Treatment of suicidal patients: A risk‐benefit analysis

Overholser

1995

Behavioral Sci & The Law

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“…Historically, individual clinicians and agencies established the requirements for the contents of these records. MFTs, like other psychotherapists, are apprehensive about the prevailing external factors, (e.g., HIPAA, increasing malpractice litigation, insurance rates) that are impacting recordkeeping practices (Reamer 2006;Soisson et al 1987). These external factors demand that therapists account for their interactions with clients by means of progress notes (Gehart 2009).…”

Section: Introductionmentioning

confidence: 98%

How Master’s Students Document Stability and Change Within and Across Progress Notes

2009

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To address a gap regarding how clinicians record progress in therapy, the researchers conducted a qualitative study of de-identified progress notes from a universitybased brief therapy training clinic. The researchers described trainees' stability and change documentation with respect to problem-oriented and solution-oriented talk in their progress notes. The patterns were (a) problem-oriented stability and problem to solution change within first sessions; (b) problem-oriented and solution-oriented stability within last sessions; and (c) stability (e.g., problem to problem) and change (e.g., problem to solution) across first and last sessions. Findings suggest that first session problem and solution outcomes do not necessarily predict last session outcomes (i.e., problem continuation or change to solutions).

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“…Record keeping is likewise vital if the practitioner is to provide consistent service, taking into account all the relevant elements of the treatment (Jenkins, 2007). Record keeping may also be important for other reasons: for instance, in many professions, practitioners may be required to give evidence in a court of law (Soisson, Van de Creek, & Knapp, 1987). These ethical protocols are not only recognised as standards for good practice, but are upheld through various mechanisms, including being embedded into the training and accreditation of these professions, and monitored by regulatory bodies.…”

Section: What Are Ethics?mentioning

confidence: 99%

Professionalising positive psychology: Developing guidelines for training and regulation

Lomas

Ivtzan

2016

Intnl. J. Wellbeing

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Although positive psychology (PP) was initially conceived as more a shift in perspective (towards the "positive") than a new field per se, in pragmatic terms, it is arguably beginning to function as a distinct discipline, with people self-identifying as "positive psychologists." Thus, we contend it is time for the field to start developing a system of professional (e.g., ethical) guidelines to inform the practice of PP. To this end, we outline one such possible system, drawing on guidelines in counselling and psychotherapy. Moreover, we argue for the creation of two tiers of professional identity within PP. Firstly, people with a master's qualification in PP might label themselves "positive psychology practitioners." Secondly, we raise the possibility of creating a professional doctorate in PP which would enable graduates to assume the title of "positive psychologist." We hope that this paper will contribute towards a dialogue within the field around these issues, helping PP to develop further over the years ahead.

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Thorough record keeping: A good defense in a litigious era.

Cited by 28 publications

References 9 publications

Treatment of suicidal patients: A risk‐benefit analysis

Treatment of suicidal patients: A risk‐benefit analysis

How Master’s Students Document Stability and Change Within and Across Progress Notes

Professionalising positive psychology: Developing guidelines for training and regulation

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