Speak Out OCTOBER 2019 V3 DIGITAL EDITION

Clinical records

Ethics

Clinical records What’s the ethical concern?

Have you found yourself in any of these scenarios? • A solicitor requests a copy of the speech pathology file for a client who is seeking compensation from WorkCover for a workplace injury, and a report to indicate how much more speech pathology intervention the client will require. • Your practice manager brings you a letter from a large Private Health Fund, stating that your files for 10 clients have been randomly selected for an audit. • A child has been brought in by her mother and, although you have a copy of the parenting order stating there is shared responsibility between the parents, you have never had contact from the father. The father now emails you to request a copy of all the progress notes so that he can understand what has been happening with his child. You are not sure whether the father has another motive for asking for the file notes, but you are aware that he is entitled to any information about his child. • Another speech pathologist in your practice must take sick leave unexpectedly and you are asked to see some of her clients. You haven’t had any time for verbal handover, but you are confident you will be able to continue with therapy, guided by the progress notes in the client’s file. The first session is scheduled in 10 minutes. How do you manage these situations if you open the client file (electronic or hard copy) only to find that there is an initial assessment report but nothing else? Speech pathologists are aware that keeping appropriate client records is key when providing professional services. Complete and accurate records support: • confirmation of consent for treatment; • confirmation of the use of ethical decision making through the identification of evidence-based interventions for a particular diagnosis; • continuity of client care; • safety of care – clinical decisions must be made on evidence, which is difficult to achieve if there is no record of sessions; and, • fulfillment of obligations to third party funding providers or employers.

None of this information is new for speech pathologists. However, an increasing number of contacts to national office include concerns relating to maintenance of appropriate records. There are many reasons why a clinician may fall behind with record keeping. It is worth being mindful of processes that can support the maintenance of good clinical records. If you or your staff are consistently falling behind in maintaining clinical records it may be worth considering: • What policies are in place in your practice to support appropriate record keeping, e.g. are clinicians required to complete file notes within 24-48 hours of a session, and how do other policies and processes support that? • Is it acknowledged that record keeping takes time, do staff have appropriate time scheduled for writing notes? • Do you schedule enough time for yourself to keep up with note writing and record keeping? • Early career speech pathologists may need more time initially for record keeping, how are they supported to reflect on their practices in this area and ways to increase time efficiency with this task. • How does the practice identify if a clinician is struggling with timely recording in client files, how is that person supported to catch up? • Is there a regular audit performed to check files are complete and entries are of an appropriate standard? Why is this an ethical issue, as well as an operational issue? Speech pathologists have an ethical obligation to keep accurate records of the professional services provided to clients. These obligations are stated explicitly in the Code of Ethics (2010) such as Standard 3.3. This standard includes the obligation to ‘keep appropriate documentation, particularly in support of client choice of interventions and their outcomes’. The ethical obligations relating to maintenance of clinical records can also be found in other areas listed in the Code, such as the obligations to exercise due care and attention to detail (Standard 3.2.1), provide benefit to clients and prevent harm (Principle 2.1), provide accurate and timely information to clients (Standard 3.1.2), compliance with federal and state laws (Principle 2.5). Resources for members can be found on the SPA website on the Professional Resources tab, including an article from Guild Insurance discussing the risks of not keeping appropriate clinical records, and a checklist to evaluate whether your practice is achieving appropriate maintenance of clinical notes and meeting ethical obligations.

Trish Johnson Manager Ethics and Professional Issues

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October 2019 www.speechpathologyaustralia.org.au

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