risk management for mental health clinicians
DESCRIPTION
The Nuts and Bolts of Legal and Ethical PracticeTRANSCRIPT
Risk Management for Mental Health Clinicians
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The Nuts and Bolts ofLegal and Ethical
PracticeEdward L. Zuckerman, PhD
Agenda for todayI. Overview: Self-protection. Theme 1: Build it into your paperwork and procedures.
2. Managing risk: Theme 2: Slippery slopes. Theme 3: Loyalty. True risks vs hype. Spectrum of risk. Theme 4: We create the risks. Data, Changes in ethical understandings.
Break
3. Standards of practice: Offenses. Values, Ethics. Fiduciary duty. Knowing the standards. Consulting.
Lunch - Make new friends
4. Licensing boards and complaints: Real risks vs hype. Four kinds of bad news. Data. Malpractice. Complaints: who, when, why, how. Comparing Suits and Boards. Responding to a formal Complaint or a Suit. Releasing records. Amending records. Soliciting complaints.
Break
5. Documenting: Permanency. Retention. Professional will. What to record. Rules of thumb. High-risk situations. HIPAA: Required contents and changes coming. Diagnosing: ICD vs DSM.
6. Competence: Self-awareness. Excessive optimism. Monitoring.
7. Patient education: consenting: Definition. Methods.
8. Buying malpractice (Professional Liability) insurance
Wrap up and your CE certificates6
5. Documenting
Documents are very protectiveRecord retention rulesRecord destruction Professional willWhat to record Rules of ThumbHigh risk situations
HIPAAICD-9 and DSM-5 and ICD-10
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•Insurance - “released” by client
•Mandated reporting
•In litigation, HIPAA’s Psychotherapy Notes will very likely be discoverable
•In a suit the client has “waived privilege” but not all confidentiality - law ≠ ethics ≠ Board
•Judges decide, no matter your arguments
•Confidentiality does not end with death
Exceptions to confidentiality
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What to record: Some Rules of Thumb
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Our Progress Notes can and will be read by anyone
with an interest in them
•Every reader will have a different background and intents and so make different interpretations of your words
•Jargon can be confusing
•Our abbreviations and acronyms are obscure or ambiguous to others
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Record only what is relevant
to your work
•Discretion, discretion, and more discretion
•Leave out most specifics
•Anonymity: Omit names of most third parties. Use initials rather than names?
•Maintain a "Professional voice":
• No sarcasm, irony, exaggeration, or attempts at humor.
• A too casual a tone may reflect badly on the clinician.
• No pejorative labeling of clients as bigoted, fat, selfish, sick, stupid or behaviors like degrading, unethical, criminal, or illegal.
• Separate the disorder from the person. No “mental retardates” or “addicts” or “alcoholics,” etc.
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“If it wasn’t written down, it didn’t happen”•While “skimpy records imply skimpy
treatment” documenting has to be balanced against the time and energy required for record making
•Impossible to record everything that happens•Eric Harris: “Show your work” for partial credit
•An aside: undocumented progress and success: clients’ compliments and reports of improvement 9
4
If it might make a mess,
make a note• Your vague discomfort is learned unease - it is the product of good professional education and experience
• Write at your current level of understanding
• More unease, more risks, more notes
• Never open a high risk issue without closing it in your notes
• These notes will demonstrate your thoughtfulness, your competence, your adherence to the standards of practice 9
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“Think out loud for the record”
Write down your thoughts as a clinician thinking through the situation:
• The concerns, questions, or conflicts
• What you don’t know and want to learn
• The risks and liabilities of taking and not taking each action - the cons - and the benefits - the pros- of each action
• Your decisions and plans
This is a valuable experience for care of the client
and is your main defense in a complaint or suit96
A well-made and documented decision
does not guarantee a good outcome nor
prevent your being sued/complained against
BUT it is very good evidence of proper practice and the best
defenseThe process does have to be thoughtful
The process does have to be documented
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Diagnose properly
•Diagnosing is required of health care providers
•Don’t “tailor the chart”
•Diagnoses using ICD-9 are required by HIPAA
•You can add DSM, “Psychodynamic Diagnostic Manual” diagnoses, as well as interpersonal, etc
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ICD-9 is theInternational Classification of
Diseases, Ninth Edition,
Clinical Modification,Chapter 5, Mental disorders from the World Health Organization,
Geneva• Insurers use (non-public, non-standard) programs to “crosswalk” DSM’s into ICD’s diagnoses
• DSM and ICD are not identical: • Dozens of diagnoses are unique to each• Old categories from DSM-III are in ICD-9 -eg 312
• ICD is more current than DSM - eg V-codes
• Where can I find the ICD? 107
The Centers for Disease Control in Atlanta, GA
www.cdc.gov/nchs/icd/icd9cm.htm
•Free.
•But not a brief listing - just the whole 15,000 diagnoses, yearly updates, addenda, etc.
•So go to ‘ICD-9-CM,’ then ftp (download) the ‘Folder DTAB1.1Zip,’ and ‘unzip’/expand it.
•Then focus on the 32 pages in Chapter 5 - pages 161-193
•Also look at ICD-10, ICF, and training materials.
ICD-9 Diagnoses
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ICD-9 Diagnoses - 2Rapid Coder - 2009
Psychiatry
Plastic card
RC17 - $19.95 plus shipping.
2 pages so it is cramped, tiny print, hard to read, one color
Listed alphabetically!
Ingenix - Behavioral Health 2009 Fast Finder “approximately
300 of the most commonly reported
codes”-not all the codes.
Laminated or downloadable#28994 - $24.95 plus shipping.
2 pages - cramped?
<- this is not the product
ICD-9 Diagnoses - 3
Ed’s Reference List of Psychiatric Diagnoses
• 4 large pages.
• Heavily laminated or just coated paper.
• Multi-color for clarity
• All psych & sleep disorders, substance abuse, brain injury, latest changes, etc.
• $12.95 and free shipping,
• $10 or $5, here.
Future diagnostic resources
ResourceUnited States
Rest of world
DSM-IVDSM-IV-TR
Now (since 1994 and 2002 with no
updates)
?
ICD-9Now
(since 2003 and updated yearly)
up to Dec 2008
ICD-10 Oct 2013 Now (since Jan 2009)
DSM-V May 2013 ?ICF and ICHI
? 2007 and on
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6. Competence
Overconfidence
The Dunning-Kreuger/Lake Woebegone Effect
Self-monitor
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Bear in mind the limits of your competence
You are NOT competent to treat everyone whom:
•You see in your office
•You are licensed to treat
•You are trained to treat
•You want to help111
Incompetent and UnawareThe Lake Woebegone Effect: 85% of drivers
rate themselves as above average.
Kruger (1999) : Areas of skill and knowledge: Humor, aesthetics, etc. all without objective standards.
Results:
1. Bottom quarter (mean at 12th %ile) rated themselves as above average (58th %ile in humor, 68th %ile in logic)
2. Top group (mean at 86th %ile) rated themselves as 68th %ile in logic.
The only cure for this distortion is becoming competent. 112
Monitor yourselfYou must perform at the standard of practice
so you must monitor yourself. •Get retraining regularly to prevent drifting and learn new developments.
•Get CE in newer treatment approaches and issues/concerns.
•Stay within the limits of your competence.
•Be realistic, not grandiose, arrogant, or defensive.
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Monitor yourself - A summary•Don’t be greedy, needy or choose
from a fear offending referrers or bosses.
•Don’t work when impaired.
•Learn and remember your weaknesses.
•Collect data on client progress and your outcomes.
•Take pride in the quality of your work, despite
•external pressures and judges.
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7. Patient education
Consent: Informed, competent, voluntaryFive paths to consent Your practice brochure A structured interviewContinuing consentingUsing handouts
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Patient education - ConsentTo be considered valid consent must be
all of these:Informed+
Competent+
Voluntary
Free
choice
Capability
Discussion
Consent
because all of these
existed -> 117
Consent must be ...Voluntary - Client can discontinue or
refuse your services at any time with only the loss those benefits
Competent - Capable of understanding the options and anticipating their consequences
Written? - No, but better than memory or testimony
And Informed ... 118
Informed consent is ...... the mental state resulting from
a discussion, with questions and answers, exploration of concerns, and information sharing
A signed form certifies/publicly acknowledges the consent - it does not assure or replace it
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The “hows” of informed consent
Five Paths:1. A set of questions to be asked of
you by the client.
2. A Practice Brochure
3. A list of Patient’s Rights.
4. Contracts for therapy, assessment, etc.
5. Consent forms for specific interventions.
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1. A structured interview the client
does on YOUWhat topics? •From the list to be considered for your Brochure for Clients
•Rephrased as questions
Example:A. Tell me about money
• What is your fee for how much time?• Will you ever charge me more?• How do you want to be paid?• Do I have to pay for appointments I forget or cancel?
• Will I have to pay for phone calls or letters or emails?
• If I lose my job can my fee be less?• If I don’t pay you what will you do?
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2. Your practice’s brochure
•A comprehensive, written, read, discussed, and signed patient information and education brochure addressing all relevant issues
•Explicit about responsibilities and obligations
•A contract; legally binding
•Titles: Information for my clients, Welcome to my practice, Informed consent, What to expect
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Q: When is more consent needed?
A: When more information is needed:
•New or changed risks.
•For any especially sensitive area.
•Unfamiliar or unexpected actions will be used.
•Experimental or unsupported treatments are offered.
Therefore consenting/collaborating is an ongoing process.
How? More specific handouts.123
Patient education handouts
On issues such as:
•Multiple relationships - never sexual, “not friends”
•Managed care’s limits and risks
•Those who have been sexually exploited.
•Confidentiality between parents and especially, older kids.
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“Informed consent” with an almost-adult
Combine:
•A Consent (by parents) to your withholding some information about or from the teen with parents.
•An Assent (by the teen) to allow the clinician to share some information about the teen with parents.
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8. Buy insurance
•Occurrence vs Claims-made: when for each?
•Understand the features and exclusions of any insurance - Get and read the Specimen policy.
•Weigh the buying of a “rider” for greater legal defense coverage against your risk.
•Get “Premises liability” - slips and falls - coverage.
•When you retire:
•Buy or get a nose/tail (Prior Acts coverage).
•Raise your coverage level in last year of premiums.
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8. Thank you!If you liked it, tell your friends and PESI.
If you didn’t, tell me (anonymously if you prefer).
by email to [email protected]
and for our neat tools see
www.TheCliniciansToolBox.com
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