Ethics and Case Note Writing
Caitlin J. McCredie
March 4/2014
Introduction
Imagine your client who was sexually abused is in court testifying
against a sexual abuser. You have been seeing your client for a year
since the incident. All of your counselling files has been subpoenaed
and are being used in the defences case. Your client has disclosed
much of her life regarding her relationships with others, drug and
alcohol use among other things. Your client has had 2 abortions. All of
this is documented in your case notes which are now being used a
hook for the defence.
This is how ugly things can get when ethical case note writing is not
practiced. Ethical dilemmas of what to write or what not to write can
happen all the time in the counselling field. However, if proper
guidelines are followed there are ways to protect your client, and
yourself.
The Counsellors Responsibility
“Counsellors have a primary responsibility
to respect the integrity and promote the
welfare of
their clients. They work collaboratively with
clients to devise integrated, individualized
counselling plans that offer reasonable
promise of success and are consistent with
the
abilities and circumstances of clients.”
(McMahon, Schulz, & Sheppard, 2007)
Ethical Dilemma/Area of Research
The ethical dilemma that I will be discussing in this
presentation is how much or how little is ethically correct to
record in client case notes and client files in counselling.
I will do this by discussing my experiences with case note
writing in my internships, using information from the CCPA,
discussing the importance of case note writing, defining
confidentiality and its limits, going through practice ethical
dilemmas, including a presentation on ethical case note
writing I was able to attend, and presenting questions open
for discussion.
Ethical Case Note Writing
First, I would just like to explain why this topic is important to me and
why I chose to research it.
I did not know much about case note writing when I entered my
internships, and I did not really have to do any of it in my junior
internship. It was really shocking to me that when I began my senior
internship I was totally out of the loop.
It seems to me that there is so much gray area regarding case notes
and client files, and this can be quite alarming. As a counsellor, client
confidentiality and safety should be at the forefront of practice. This
includes what goes into a client file. To be able to write case notes
ethically is a challenge.
I also thought this would be a good topic since everyone will have had
different experiences with what was required at their agency.
Why keep client files?
In most counselling agencies, case notes are taken recording sessions with clients. This is
helpful for the counsellor to be able to reflect on the session, keep thoughts organized, and
to create a treatment/session plan for their clients. These files can also serve as evidence
that the counsellor is in good practice, and demonstrating positive change in the client.
Other things that may be in a client file are: contact information, address, occupational
information, health information and the informed consent and confidentiality agreement
between that counsellor and client. Typically, this is a document which is signed in the first
or second session with a client.
According to the CCPA, it is a counsellors responsibility to keep up to date notes on their
clients, “Counsellors maintain records in sufficient detail to track the sequence and nature
of
professional services rendered and consistent with any legal, regulatory, agency, or
institutional requirement. They secure the safety of such records and create, maintain,
transfer, and dispose of them in a manner compliant with the requirements of
confidentiality
and the other articles of this Code of Ethics.” (McMahon, Schulz, & Sheppard, 2007)
“The CCPA Code of Ethics lists the limits of
confidentiality:
Counselling relationships and information resulting
therefrom are kept confidential.
However, there are the following exceptions to
confidentiality:
(i) when disclosure is required to prevent clear and
imminent danger to the client or others;
(ii) when legal requirements demand that
confidential material be revealed;
(iii) when a child is in need of protection.”
(McMahon, Schulz, & Sheppard, 2007)
When Confidentiality Must Be
Breached:
After reviewing what the CCPA lists as the limitations of confidentiality, we can
see that there are many situations that counsellors will come into contact with
in which they may be facing this ethical dilemma. No counsellor wants to
damage the rapport that they have developed with their client. This can be
painful for the client and the counsellor, and can damage the therapeutic
relationship that has grown between them. Thankfully most counsellors can rely
on their agency for support for themselves and their client when confidentiality
must be breached. (McMahon, Schulz, & Sheppard, 2007)
However, I would like to focus on the second point in the CCPA code of Ethics
definition of limits of confidentiality, “when legal requirements demand that
confidential material be revealed” (McMahon, Schulz, & Sheppard, 2007). This is
not something that ever happened to me in my internships, but it was
something I talked a lot with my supervisor about.
What would happen if the files a counsellor has kept on their client were
subpoenaed by the courts? Would this counsellor be in some kind of trouble?
Would the client? How can what a counsellor keeps record of be dangerous to
the client?
What We Write Down Matters?
Yes, ethically speaking, the types of things you write in your clients
case notes matter. The language in which a counsellor writes their
case notes matters. And, the amount of detail or lack of detail
certainly matters.
As counsellors it is our responsibility to keep our clients safe, and
we can do that by using ethical case note writing when
documenting client sessions.
So how can what we write about our clients harm them? Why cant
we just write everything the client said in the session down? We
cannot do this because if for some reason that file were to be read
in court, that would be very harmful to client. On the other hand if
we write down fewer details and keep things concise, some of our
clients privacy can be protected.
A Practice Situation
Your 25 year old female client comes in for her weekly session and it is
proceeding as normal. You decide to do a genogram with your client. Your
client discloses years of alcohol and drug abuse by nearly all members of the
family. The client explains that her mother was drinking while she was
pregnant with a child and miscarried. This was very traumatic for your client,
but you have created a very safe space and your client is happy to share their
past with you. Your client also talks about the many years she spent as a child
feeling like there was little to eat around the home, and they way her mother
and father had done little to ensure that their children were clothed and fed.
Your client has a relationship with her parents today. You decide to do a
therapeutic drawing exercise to get grounded before ending the session and
your client draws a picture of a cat.
Before going on to the next side, think about what kind of detail you would
include in a case note about this session.
Which of these is right?
Many Details
Client disclosed watching her
parents abuse alcohol for much
of her young life. She reported
having been hungry and uncared
for by her parents and remains
sad about this. The client said she
saw her mother have a
miscarriage that was caused by
alcohol consumption.
Few Details
Theme of session was childhood
and family trauma. Client
reflected on meaningful past
experiences. Grounding exercise
was completed.
Which of these is right?
There is no right or wrong answer.
Before proceeding, reflect on your experience writing
case notes, and consider which style best protects your
clients right to confidentiality.
How to Write Ethical Case Notes
I was able to take in a presentation on Ethical Case Note
Writing by Dawn McBride last semester. She is an
associate professor at the U of L and is a private
practice psychologist. During her presentations she
covered 13 areas that should be considered to avoid
ethical dilemmas with clients and case note writing. Her
job previously has been to work in court when
counsellor files are subpoenaed. It is important to
remember that any form of recorded information is
considered to be a record that can be subpoenaed.
How to Write Ethical Case Notes
1.
It is important to only record the information that you
absolutely need. Keep in mind when writing case notes
on a client, that this is YOUR case note and it should be
written for yourself, not for an audience. Less is more in a
case note because it should only trigger your memory of
details.
2. Don’t ever state that something your client said is a fact
in their case notes. Use words like, “Client stated,” or “he
explained.” This is important because you don’t know if
what your client told you is true, and you don’t want to
be held accountable for this.
(McBride, 2013)
How to Write Ethical Case Notes
3. Keep this case notes private to the best of your ability. Ensure that the
printer you use is also private.
4. Describe your clients behaviour but don’t diagnosis it. Say things like, client
displaying anxiety by______. Don’t say, “client was experiencing an anxiety
attack.”
5. Take notes during the session to ensure accuracy.
6. Don’t use long paragraphs to explain a story.
7. Do not record names of your clients in your daytimer.
(McBride, 2013)
How to Write Ethical Case Notes
8. Don’t keep two sets of notes. This means, if you have taken informal notes in a
meeting, relay them into your formal notes and destroy the informal ones.
9. Keep separate files for all client involvement in your agency.
(Individual/group/couple/family counselling should all be separate notes.)
10. Record any phone contact you have with your client.
11. If you receive a disclosure of abuse, but sure to record the action you took.
(CPS/Police/SRO)
12. Don’t include the clients narrative of their life or “diary” into the case note.
13. Ensure you always record harm to self or others.
(McBride, 2013)
Putting it All Together
So how does this relate to addictions counselling?
It is important to have a case note writing format in
your agency or practice, to ensure the protection of
yourself and your client. Lets look at another practice
situation and using the steps provided from the ethical
case note writing seminar, create a session summary.
Putting it All Together
Practice situation:
You have been seeing a client for several weeks now in your private
practice. This female has issues with alcohol and drugs, and has just
disclosed that she prostitutes herself in order to fund her addiction.
This female is 24 years old and has suffered much trauma since her
childhood which she disclosed to you during this session. This client
also disclosed to you that she was a witness to a crime many years
ago, and this bothers her often. You decide to use some creative art
therapy for grounding, and play with some clay. She moulds the clay
into what looks like a baby. You ask her to explain her piece and she
says she recently had an abortion, but she has not disclosed this to
family or her partner. Session ends and you are due to see her again in
1 weeks time.
What do you think?
 If this was your client, what would you include in the case
note?
 Have you ever had to write case notes?
 Does/did your agency have a policy/template for case
notes?
 Do you think case notes should include all details, or be
kept to themes and generalizations?
 If you have not had to write case notes before, what were
your thoughts before this presentation on what case notes
should look like?
Conclusion
Thank you for viewing my presentation. Case note
writing was a huge challenge for me in my senior
internship and I learned a lot during that time. I hope
that you can take something from this presentation
with you and I hope I can answer any questions the
class might have from this presentation.
References
McBride, D. (2013, October). Ethics: consent & record
keeping in counselling. Professional development.
Lecture conducted from the University of Lethbridge,
Lethbridge, Alta.
McMahon, S., & Schulz, W., & Sheppard, G. (2007). The
code of ethics: Canadian Counselling and
Psychotherapy
Association.
Retrieved
from
https://moodle.uleth.ca/201401/pluginfile.php/46
858/course/section/1064/CCPA%20CodeofEthics_
en_new.pdf