Preparing for Court

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Preparing for Court
Scott Pelking, LPC-S
DISCLAIMER
I am not an attorney, and the information
conveyed in this presentation should not
be construed to be legal advice. It is no
more than a reflection of literature,
information gathered from other
workshops, and personal experience.
In all instances regarding the law, please
consult your own attorney.
Documentation
You did document your cases, didn’t you?
Progress notes vs. clinical
(psychological) notes
• Progress notes consist of primarily of
demographic information, mental status,
progress made, and the plan for the
next session. These are usually
required by insurance companies and
requested by the court.
Progress notes vs. clinical
(psychological) notes
• Psychological or clinical notes are those
narrative notes which describe and
analyze the particulars of the session.
These may be kept separate from the
progress notes and may go to court if
they are specifically requested.
Writing with court in mind
• Whenever you write a progress or clinical
note, assume that one day it will end up in
court.
• Keep your notes clear and your opinions
clinical.
• Use good grammar.
• Avoid complex sentence structure–it’s a note,
not a work of literature.
• If a note can be misinterpreted, it will be–or
will seem to be. Avoid ambiguity as much as
possible.
Reviewing notes prior to
court
• Always review your notes before they
are sent to the attorney who requested
them.
• Ensure that they are complete, in
chronological order, dated, signed, and
are for the right client.
• If clinical notes were not specifically
requested, check with your supervisor
(or, better yet, your attorney) about not
sending them.
Interpreting your notes
• Preview your notes the day before you
go to court. It’s often wise to flag
important information so you can
access the page quickly.
• Scan your notes when you arrive at the
courtroom and before you testify.
Remind yourself of any information your
client’s attorney requested of you.
Interpreting your notes
• Know what you’re talking about.
• Focus on important facts, and be
prepared to explain any of your
comments. REMEMBER: The attorneys
will usually have copies of your
documentation, and they will be
following it word for word.
Interpreting your notes
• Don’t say any more than what was
asked for. Remember: ATQASU
(answer the question and shut up).
Reading your own writing
• Use standard, accepted abbreviations if
you must use abbreviations
• If you really can’t read a note, admit it
rather than try to fake it.
• Be sure that you can correctly
pronounce the words in your notes–
especially the client’s name, the
diagnosis, and any technical terms you
may have used.
Dealing with Records
Requests and Subpoenas
Confidentiality/HIPPA
Include copies of permissions with
the documentation
Include documentation covered by
the permissions ONLY; you may
need to acquire additional
permissions for documentation not
specified in original permissions
document
Joint Custody
Ensure that you have permissions
from both parents
Make sure that the request for
documentation is legitimate, and not
a “fishing expedition” of one party
towards another. You may consider
a clinical summary as opposed to
releasing the notes.
“Reasonable Time”
o The court must give you a reasonable
amount of time to respond to the
subpoena: at least 24 hours.
o Subpoenas may be blocked, but only
by an attorney and only for reasonable
causes.
The Court Environment
• Adversarial vs. nurturing
– Realize that attorneys have a job to do,
and that they are used to “winning” and
“losing” cases.
– You will be tested.
The Court Environment
• “Drama” of court
– Attorneys at time acknowledge that the
court proceedings are like a play, and
you are a secondary player
– Much of what goes on is “for show,”
trying to convince the judge or the jury
to prefer one side over the other. That
doesn’t mean that it’s not important, or
you can’t get hurt.
The Court Environment
• Understanding your role
– Factual witness:
• you may not opinions about your findings
• You may only answer “yes” or “no” questions
– Expert witness
• You may--and are expected to--give your
professional opinion
• Must be established before the court
The Court Environment
• Dealing with nervousness
– For whatever it’s worth, the attorneys
are nervous, too.
• Holding your temper
– Very important in order to help your
client; remember your role in the
proceedings, remember that the
environment is different, and the game
is different as well.
Things That May Prove Helpful
 Having--and being able to explain--your
therapeutic theory and being able to
show how it is applied to your therapy,
as demonstrated in your notes
(actually, you’re required to do this)
Things That May Prove Helpful
 Understanding testing and validity (if
you have done testing or are using test
data to substantiate your diagnosis and
treatment plan). For example, how does
one violent act on a client’s part not
invalidate his profile for nonviolence
according to your testing results.
Things That May Prove Helpful
 Be able to explain clinical concepts in
layman’s language, and how your
treatment is valid in addressing your
client’s issues. How do you translate
what happens in your therapy session
to people who don’t understand what
we do?
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