When you decide to seek clinical consultation, there are 5 things that you should document in your clinical notes. They are the 5 W’s:
- When you seek consultation;
- Why you are seeking consultation and why now;
- Who you are seeking consultation from;
- What opinions / information / recommendations you are receiving from that person even if they contradict your own clinical judgment;
- What your final professional opinion / plan is and why you are / are not going to go along with the recommendations received.
"Questions" by Tim O'Brien / Oberazzi
In other words, your clinical rationale all along the way needs to be documented in your notes. Why? To protect both you and your client.
Should you end up in a malpractice suit (which is quite possible), your proper documentation will assist you in explaining your thought process concerning your work with your client. Likewise, should anything happen to suddenly prevent you from continuing to work with your client, your general direction of treatment can more likely continue seemlessly because you have taken the time to thoroughly document your clinical rationale and intent.
Thanks for this list Tamara. I had not considered putting in my consultation notes why I decided to seek consultation now. While I document their advice, I have not specifically documented what direction I chose to go. I guess I thought it would be evident in subsequent client notes.
This may be a stupid question, but I’ve never been clear on this: Do consultation notes go in the client file? That’s where I have always put them. I hesitate each time, because when I picture the client asking for a copy of their file I feel uncomfortable about them seeing my thought process.
Of course, as I write this, I guess my thought process is exactly what I want seen, especially in a lawsuit.
Hi, Tawnya! Welcome back! You are so welcome.
Yes, the consultation note really does go into your clinical record . . . and, in large part, that potential for a lawsuit is exactly why you want it there. Documenting your thought process allows you to present yourself as a conscientious and methodical therapist who has a plan for what to do when you get stuck – as we all do from time to time. 🙂
Documenting the “thought process” can also be done in a psychotherapy note, which is separate from the clients medical records and has additional HIPAA protections. Why not document the consultation in a separate psychotherapy note instead of making it part of the clients medical record?
Hi, Karina! Thanks for dropping in!
Consultation is often undertaken as due diligence in a therapist’s work.
If / when called to court, a therapist is often asked to prove that she has “done her due diligence.”
If the documentation of consultation is not included in the client’s record, then it is infinitely more difficult to “prove” that consultation was engaged in.
And, if a record must be passed on to a subsequent therapist for whatever reason (including the original therapist’s death), it is often helpful for a therapist following up with that client to see and understand the original therapist’s thought process and reasoning for the work she has done.
By including the note on consultation in the client’s record, you may be facilitating a smoother transition of care as well as mitigating liability for yourself.
Can you think of a circumstance where you might not want consultation to be noted in a client’s record? Why might that be the case?