The article by Jim Jensen on Treatment Planning in the current issue of The Addiction Professional includes important information for all addiction professionals and it relates ethical standards. In the revised NAADAC code of ethics, Principle IV, Standard 3 establishes ethical guidelines for maintaining records and data. For many years, treatment planning and progress notes for clients have been considered something that has to be done, but not that important. With the transition to electronic records, records will be more readily available and more easily reviewed by others. Legally the paper documents belong to the agency and the content belongs to the client. The standard relating to ownership of electronic records has yet to be decided.
Clients might request a copy of records for various reasons or an accrediting agency might be reviewing client records for compliance. What are the legal and ethical issues if the records do not provide the necessary documentation related to treatment goals and progress made (or not made) during treatment? The credentials of the addiction professional(s) writing such records might be at risk in certain situations and clients are impacted by being dependent on those records to prove compliance.
For example, a client may need documentation of the presenting issues when entering treatment, treatment goals and proof of treatment success to meet court or employment stipulations. In such cases, a written record is essential for the client's well being. Laws and regulations require that the treatment plan be individualized and reflect identified client needs. Progress notes must reflect progress towards the treatment goals. Client documents/records that assign the same goals to every client are common but do not conform to ethical or legal standards. How can this practice be defended in court?
A client records case that came up a number of years ago related to an agency where client records were thought to be unimportant. The owner of the agency knew that when the agency was audited, only four records were reviewed. The auditor allowed the owner to choose the records to be reviewed. At this agency it was standard procedure to maintain records on only four clients. What are the risks to the clients? The agency? The addiction professionals who knew about this practice?