The Legal Aspects Of Recordkeeping And Expert Testimony
The Legal Aspects of Recordkeeping and Expert Testimony In today’s society there is an ever increasing need for professional psychologist practicing in the field to keep detailed records of their professional services offered to clients. This need has grown in proportion that these records are often referred back to it often times, legal settings. In this work a brief survey of what is determined ethical as it relates to the professional psychologist role in recordkeeping and providing expert testimony to the general public. Several issues of ethics arise, from the initial consultation, throughout, and up to providing expert testimony in a court of law.
Ethics play a significant role in this process. Comment by Andrea Dillon: My computer is correcting it to ever-increasing, I guess both could work. Comment by Andrea Dillon: 1) I think we should revise this sentence. 2) We are repeating words Ethical Issues to Documenting Informed Consent Several ethical factors start from the onset of a professional psychologist initial meeting with a client. Fisher (2013) quoting from APA (2010) state: Psychologist create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analyses, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law (p. 178). This standard enacted by the APA, sets in place the standard of documenting from the onset. This documentation in all practical purposes covers the professional psychologist when issues arise by releasing any information. It goes on to the process of disseminating client record to parties outside of the psychologist client relationship. The ethical standard in general states, document, and release only to those parties who have determined a need to know, after authorization has been given for such release.
Comment by Andrea Dillon: 1) I think we should revise this sentence. 2) We are repeating words Enforceable Standards on Record Keeping The following are the relevant enforceable standards on record keeping: 6.01 Documentation of Professional and Scientific Work and Maintenance of Records Under this standard psychologists must create and maintain the records under their control to facilitate the provision of services in the future, to meet institutional requirements and to ensure compliance with law (Fisher, 2013). Detailed forensic records are important when there is a prolonged period between interviews or data collection and hearing of a case; for this reason, psychologists should create and maintain the information in a way that facilitates the appropriate use in legal settings (Fisher, 2013).
6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work This standard requires confidentiality of professional data in each stage of record construction, maintenance, distribution, and removal (Fisher, 2013). The confidential records include written, printed resources, scoring reports, audio and video materials, etc. (Fisher, 2013). The legal relationship between a psychologist and an organization should determine the record keeping procedures that psychologists must follow; additionally, psychologist should guarantee that confidential records are retained protected from personnel that do not have authorization to review the records (Fisher, 2013).
Specific Examples – Add Mines Proposed Actions – Add Mines Legal Issues and Examples All information within the field of psychology including assessments, testing, and diagnosis documentation, that is obtained from participants/consumers must be kept confidential by law as well as APA ethical standards. Special protocols are kept in place in order to protect confidentiality such as letting the individual know that confidentiality was broken whether it was intentional or not. If confidentiality is broken, the individual is able to seek legal action against the company that broke confidentiality. The following is an example of a breach in confidentiality. If a consumer spoke with his psychiatrist and informed the psychiatrist that he had been raped in the past and experiences flashbacks as a result. The psychiatrist utilizes this information to give the individual a Post-Traumatic Stress Disorder (PTSD) diagnosis. The consumer’s friend then comes in later in the day for a session with the same psychiatrist, and the consumer informs the psychiatrist that he knows that the psychiatrist sees his friend. The psychiatrist then begins to tell the friend about the rape and flashbacks that individual’s friend experiences. This information then goes back to the original consumer, and the consumer realizes that the psychiatrist broke confidentiality. Information associated with assessment, testing, and diagnosis documentation must be completed in a way that is not harmful to the participant(s)/client(s) involved (Lewis, 2002).
For instance, testing must be completed in a way that is not physically, emotionally, or mentally harmful to the participants. The individual must also be debriefed and given information for follow-up care if the individual feels that he or she may face further distress after the testing and debriefing. If the individual feels that his or her rights were violated and the individual was hurt physically, emotionally, or mentally than that individual may seek legal action due to malpractice. Suppose an individual volunteers to participate in a research study. Prior to the study the individual is informed that the test will assess characteristics of personality. The participant is not told that the test is actually meant to measure sadness because then the individual may answer questions to rate higher or lower based on that information. The
participant is then instructed to read questions and answer respectively. The participant starts to become depressed during the assessment due to the content of the questions asked. The participant is then minimally debriefed but not given information for follow-up care after the assessment. The individual commits suicide within a few days of the assessment. The family of the individual may then seek legal action and file a malpractice suit. Information within the field of psychology related to assessment, testing, and diagnosis documentation must be completed accurately. Falsifying documentation may not only lead to dismissal from employment, but falsifying documentation can also be punished by legal action (Lewis, 2002). Suppose that a counselor provided an individual with a diagnosis even though the individual did not completely meet the criteria for that diagnosis. Perhaps the counselor gave the individual the criteria in order to bill. Suppose that the client later be tried for murder, and the diagnosis be used to benefit the client when the client did not actually meet the diagnosis. Falsifying information in this case may have let a guilty person off of being put away for murder. Rationale for the Examples The first example indicates how psychologists can affect confidentiality with their irregular practices. Standard 4.01, Maintaining Confidentiality establishes that psychologists must protect any confidential data of their clients to respect their privacy and dignity (Fisher, 2013). To maintain confidentiality, psychologists must store evaluation notes, therapy reports and client’s records in a safe manner, such as locked cabinets or protected computer files (Fisher, 2013). The second example shows a lack of ethical procedures during the assessment, and the possible legal effects. Standard 9.02, Use of Assessments indicates that the correct use of assessments in psychology can help persons, families and organizations through clinical information that may contribute to the person’s health, legal decisions, program development, etc. (Fisher, 2013). Psychologists that do not follow the ethical principles during assessment and therefore provide unsupported opinions in for example, forensic settings, violates the principle of integrity and the standard 5.01, Avoidance of False or Deceptive Statements (Fisher, 2013). Since psychologists’ opinion may play an important role in a legal process, they should be aware of any personal and professional bias that may affect the assessment process; they should analyze their actions and follow the ethical procedures before providing a formal report.