The most frequently encountered error was that follow-up notes were not numbered according to the problem to which they related, leading to confusion. Staff also found it difficult to break some old habits: for years they had been expected to write notes such as Patient slept and ate well,” which were meaningless for patients without problems in sleeping and eating. However, through patient training and teaching, task force members and team leaders were able to reduce the number of mistakes. By far the most successful training appeared to be the 20-hour advanced course because it stressed the philosophy behind good treatment planning rather than mere mechanics. Staff who went through the advanced course could deal more efficiently with unexpected difficulties that arose. Although our charts have improved dramatically-to the point where they were praised by the HEW inspectors on their follow-up visit three months later, we continue to work on improving them. The task force has turned its responsibilities over to the medical records committee and the medical audit committee. Various ‘ ‘
adaptations have been discussed and implemented, particularly in the outpatient department. We believe that for such an extensive program to be effective, some leeway must be given for needed changes. The POMR is a useful format for psychiatric hospitals. Mental health workers can be trained quickly in its use. But it is essential to reach all levels of staff. No matter how good the design of a system is,it will fail unless motivated staff use it correctly. We believe that with the improvements in the charting have come improvements in the quality of clinical treatment. That impression suggests an area for further research. Finally, and most important, we believe that the POMR can be a useful instrument in teaching. It is much easier to involve all levels of mental health workers in a treatment team if they are expected to think clinically and to participate actively in the formulation of the treatment plan. Such planning is easier if it is done on a basic level, such as dealing with problems, rather than on the more sophisticated level of dealing with psychiatric concepts.U
Clinicaland Legal Issues inthe Family Therapy Record NEAL
GANSHEROFF,
M.D.
poenaed.
Staff Psychiatrist Philadelphia IVAN
(Pa.)
Psychiatric
Center
BOSZORMENYI-NAGY,
M.D.
Director Family Psychiatry Department Eastern Pennsylvania Psychiatric Philadelphia, JOHN
MATRULLO,
J.D.
Services,
Philadelphia,
suggest
that
when
deciding
what
to
Institute
Pennsylvania
Senior Attorney Community Legal
They
include in the record, the therapist should remember that those in treatment are both individuals and members of the family. They also recommend that a patient’s right to privacy be safeguarded by omitting potentially damaging or embarrassing material from the record.
Inc.
Pennsylvania
The authors present guidelines for writing family therapy records that are not only clinically meaningful but also not unnecessarily damaging to a member of the family or the therapist In case the records are subDr. Gansheroff formerly was a staff psychiatrist with the family psychiatry department of the Eastern Pennsylvania Psychiatric Institute. Dr. Boszormenyi-Nagy also is clinical professor of psychiatry at Hahnemann Medical College in Philadelphia. Correspondence should be sent to Dr. Boszormenyi-Nagy at the institute, Henry Avenue and Abbottsford Road, Philadelphia, Pennsylvania 19129.
#{149}In writing a family therapy record, the therapist must strike a delicate balance between including enough information to make the material clinically meaningful and useful and avoiding, as much as possible, the inclusion of material that may be legally damaging, shameful, or embarrassing to individual members of the family. When he makes an entry, the therapist should remember that the record may not always be left untouched in the file drawer. It may be needed by another therapist for continuity of care or used to satisfy accreditation standards. Or it may be subpoenaed as evidence in a malpractice or divorce suit or in a child-custody case. The family psychiatry department of the Eastern Pennsylvania Psychiatric Institute recently revised its format for keeping family charts and established guidelines for writing the charts. Those guidelines emphasize
VOLUME
28
NUMBER
12 DECEMBER
1977
911
the need for therapists to consider four main, somewhat overlapping, aspects when writing records: hospital accreditation standards, clinical aspects, legal aspects, and respect for patients’ privacy. Therapists working in centers accredited by the Joint Commission on Accreditation of Hospitals must pay special attention to the commission’s standards for writing medical records. Every two years the commission inspects those hospitals, including their medical necords. If the records are considered completely unacceptable, hospitals can lose, and in fact some have lost, their accreditation. The standards are contained in the Accreditation Manual for Psychiatric Facilities and nequire, among other things, that “The medical record shall cpntain sufficient information to identify the patient clearly, to justify the diagnosis, to delineate the treatment plan, and to document the results accu“i
CLINICAL
ASPECTS
Many therapists who may be quite adept at writing a meaningful, high-quality record for an individual ptient have major difficulties organizing and satisfactonily recording the wealth of complex, interrelated data obtained in treating an entire family. It is one thing to write a record on a single patient; it is quite another to write one about two adults, usually parents, and possibly several children that portrays each as an individual and yet conveys their complex nuclearand extended-family relationships. If the records are to be meaningful, both individual and family data must be recorded. Two basic questions should be asked to determine if the records will aid in the clinical management of the case and in a possible legal defense: does the chart tell what is happening in the family, and does it justify a particular therapeutic or administrative decision? As an illustration of such a justification, take the case of a therapist who, in the initial sessions, is faced with parents who want to focus only on their symptomatic child. He elects to postpone intensively exploring their marital relationship until later in therapy. He explains in the record that only a minimal marital history was obtained thus far because he felt that therapy might be jeopardized if that area were opened before the resistant parents were ready to discuss it. Specific guidelines for family charts, as well as formats in which to include clinical material, have been established for the department’s recently revised initial family report, progress notes, and closing summary. The formats were designed to be broad enough to be used by most therapists, even those with diverse orientations. Nevertheless, lince any formats on guidelines will reflect, to some degree, the viewpoints of those who Council for Psychiatric Facilities, Accreditation for Psychiatric Facilities, Joint Commission on Accreditation of Hospitals, Chicago, 1972. ‘D. H. Mills, “Hidden Legal Dangers of the Hospital Chart,’ Hospital Medicine, Vol. 1, October 1965, pp. 34-35. ‘Accreditation
Manual
912
HOSPITAL
& COMMUNITY
PSYCHIATRY
developed them, there may be some criticisms. The formats and guidelines are not intended to be the final word on family records, but rather elements that can be modified as new ideas are introduced and experience in using them is gained. Initial family report. This report should contain the name of the family and of the therapist and the dates of the sessions. Under the heading “identifying information,” the names and ages of all family members should be given, as well as their occupations, presenting problems, and source of referral. The next section is “history of presenting problem,” followed by, unless the material is included elsewhere, one on “marital and family history. Under the heading “characterization of family membens,” there should be pertinent information about race, religion, nationality, socioeconomic status, developmental history of each member, the parents’ families of origin and current relationships with them, and personality descriptions of each member in therapy. Under the heading “observations of family system” the therapist should record what goes on in the sessions, both verbally and nonverbally, between family members and between the family and the therapist. Main issues and themes should also be recorded here, as well as feelings evoked in the therapist. A section on “dynamics and treatment plan’ should include the therapist’s understanding of each member, of the family system, and of how the presenting difficulties came about. Psychodynamics, societal, hereditary, and constitutional factors should also be included. The proposed type of treatment-for example, weekly family therapy or chemotherapy-and goals should be stated. Here the therapist may also give a prognosis. Progress notes. These reports should state what is happening with the family relationships as well as with the individual family members in terms of important events in their lives and their emotional states. It should also include dates of therapy sessions, who attended them, how the members interacted, what was discussed, and the therapeutic approaches used. Closing summary. This brief summary of the entire case should include an identification of the family members, the presenting problem, the treatment pnocess, the outcome for the family as a whole and for each of the members, the reasQns for termination, and the disposition. The date of the initial and final sessions or contact should also be included. The essence of these formats is that people are mdividuals in their own right who significantly affect and are affected by their family members. Thus the formats provide for including valuable information about subjective experience and individual psychodynamics as well as a description of the family’s systemic relationships. ‘ ‘
‘
LEGAL Some solely
ASPECTS therapists for clinical
think of a clinical purposes. They
record should
as being realize,
used how-
ever, that any member of the family may at any time become involved in a legal action. Divorce proceedings, child-custody disputes, and certain other civil as well as criminal cases may arise during or after family therapy. In some instances the records may be subpoenaed. What protection do therapists and patients have against having the records opened in court? It is the physician’s or psychologist’s ethical duty to keep confidential the information he has obtained about a patient in his professional capacity. In almost every state, such information is privileged and thus may not be disclosed in a legal proceeding without the patient’s consent. A few states have extended the privilege to psychiatric social workers as well as physicians and psychologists. Regardless of the professional degree of the family therapist or whether he is protected by pnivileged-communication laws, family therapy and family-based necord-keeping raise very special problems and legal issues. Privilege and confidentiality are affected by the type of legal case involved and by the sheer fact that more than one person is involved in the therapy. For example, a husband and wife go to a therapist for marital therapy. One later sues the other for divorce. One raises the issue of mental condition in either the claim on the defense. Most state counts would consider privilege to have been waived. But what if the other party did not want that information to be brought up? Should one member of the patient-family have the right to waive the privilege to the detriment of other members of the family who may either still be in therapy or simply want their communications with the thenapist to remain confidential? That issue has not yet been directly addressed by case law or statute. An argument could be made that the patient is the entire family unit and that each member must waive the privilege before the records can be examined. Although that argument may be used successfully in a divorce case,3’4 its chances of success in a child-custody case are slim because the court’s primary concern is for the best interest of the child. Massachusetts law, in fact, explicitly denies privilege to any therapist in any childcustody case in which either party raises the mental condition of the other party. In sum, a general principle of law is that the court has a right to every person’s evidence. The psychotherapist privilege is a justifiable exception but is strictly constnued and is itself exception-laden. Most important, current law as it relates to family therapy, and records in particular, is at best unsettled. According to Sbvenko, the test of relevancy-not privilege-governs the night to nondisclosure.5 Thus a therapist-family communication is best protected from disclosure by showing that the communication would have no relevance to the issues in the case. Therefore, the therapist should be cautious about Ellis
Slmrln
v. Ellis,
SW. 2d 741 (Tenn. App. 1971). 233 Cal. App. 2d 90, 43 Cal. Rptr. 376. Psychiatry and Law, Little, Brown, Boston,
472
v. Slmrln,
R. Slovenko, p. 67.
1973,
what information he includes in the records. For example, the admission by a husband that he is coming to family therapy sessions to make his case stronger in an anticipated child-custody struggle might best be omitted from the record. If it is mentioned at all, the reference should be a vague one such as Motivations for therapy were discussed. Certainly incriminating or conclusive statements such as The wife is an unfit parent” should be avoided. How detailed the records should be will depend upon the setting in which the therapist works, the family problem being treated, and the type of litigation that could arise. As a final precaution, each adult family member should be asked to sign an agreement that he understands that all of the communications are confidential and that the therapist will not disclose any communication unless all participating members join in the waiver. If each member does sign a release, the therapist must make sure that he did so knowingly and intelligently. But until the legislatures and the courts recognize the need for an absolute privilege for family therapists, this type of written agreement will provide very little protection in the event records are subpoenaed. The lack of an adequate privilege law for family therapists has led some therapists to question whether they should keep any records at all. To be sure, accurate records are the therapist’s best defense against a malpractice suit.6 Perhaps more important, accurate records ensure continuity of care. Nevertheless, many pnivate practitioners keep no charts except the customary record of appointments and billings; others risk perjury by keeping two sets, one to be turned over in case of subpoena and the other for treatment. “
‘ ‘
‘ ‘
PATIENTS’
PRIVACY
In the course of an evaluation or therapy, patients may reveal various intimate aspects of their own or their relatives’ past or current life. They generally do so with the belief that the information will be used by the therapist to help them and will not be passed on to others except in certain situations related to their treatment. To safeguard the patient’s right to privacy, we recommend that certain damaging or embarrassing matenial not be written in the chart. Such material may include the details of sexual difficulties or an extramarital affair. In deciding how much, if any, of such private material should be included, the therapist should balance the need to have complete, useful necords against the patients’ right to privacy. The more private the material is, the stronger must be the clinical reason for writing about it. We have found that an adequate description of the therapy process can be given without including details of exceedingly shameful or damaging material. It is more important to be clear about the strategy and management of the therapy than to be detailed about private matters. Mills,
VOLUME
op. cit.
28 NUMBER
12 DECEMBER
1977
913
adaptations have been discussed and implemented, particularly in the outpatient department. We believe that for such an extensive program to be effective, some leeway must be given for needed changes. The POMR is a useful format for psychiatric hospitals. Mental health workers can be trained quickly in its use. But it is essential to reach all levels of staff. No matter how good the design of a system is,it will fail unless motivated staff use it correctly. We believe that with the improvements in the charting have come improvements in the quality of clinical treatment. That impression suggests an area for further research. Finally, and most important, we believe that the POMR can be a useful instrument in teaching. It is much easier to involve all levels of mental health workers in a treatment team if they are expected to think clinically and to participate actively in the formulation of the treatment plan. Such planning is easier if it is done on a basic level, such as dealing with problems, rather than on the more sophisticated level of dealing with psychiatric concepts.U
Clinicaland Legal Issues inthe Family Therapy Record NEAL
GANSHEROFF,
M.D.
poenaed.
Staff Psychiatrist Philadelphia IVAN
(Pa.)
Psychiatric
Center
BOSZORMENYI-NAGY,
M.D.
Director Family Psychiatry Department Eastern Pennsylvania Psychiatric Philadelphia, JOHN
MATRULLO,
J.D.
Services,
Philadelphia,
suggest
that
when
deciding
what
to
Institute
Pennsylvania
Senior Attorney Community Legal
They
include in the record, the therapist should remember that those in treatment are both individuals and members of the family. They also recommend that a patient’s right to privacy be safeguarded by omitting potentially damaging or embarrassing material from the record.
Inc.
Pennsylvania
The authors present guidelines for writing family therapy records that are not only clinically meaningful but also not unnecessarily damaging to a member of the family or the therapist In case the records are subDr. Gansheroff formerly was a staff psychiatrist with the family psychiatry department of the Eastern Pennsylvania Psychiatric Institute. Dr. Boszormenyi-Nagy also is clinical professor of psychiatry at Hahnemann Medical College in Philadelphia. Correspondence should be sent to Dr. Boszormenyi-Nagy at the institute, Henry Avenue and Abbottsford Road, Philadelphia, Pennsylvania 19129.
#{149}In writing a family therapy record, the therapist must strike a delicate balance between including enough information to make the material clinically meaningful and useful and avoiding, as much as possible, the inclusion of material that may be legally damaging, shameful, or embarrassing to individual members of the family. When he makes an entry, the therapist should remember that the record may not always be left untouched in the file drawer. It may be needed by another therapist for continuity of care or used to satisfy accreditation standards. Or it may be subpoenaed as evidence in a malpractice or divorce suit or in a child-custody case. The family psychiatry department of the Eastern Pennsylvania Psychiatric Institute recently revised its format for keeping family charts and established guidelines for writing the charts. Those guidelines emphasize
VOLUME
28
NUMBER
12 DECEMBER
1977
911
the need for therapists to consider four main, somewhat overlapping, aspects when writing records: hospital accreditation standards, clinical aspects, legal aspects, and respect for patients’ privacy. Therapists working in centers accredited by the Joint Commission on Accreditation of Hospitals must pay special attention to the commission’s standards for writing medical records. Every two years the commission inspects those hospitals, including their medical necords. If the records are considered completely unacceptable, hospitals can lose, and in fact some have lost, their accreditation. The standards are contained in the Accreditation Manual for Psychiatric Facilities and nequire, among other things, that “The medical record shall cpntain sufficient information to identify the patient clearly, to justify the diagnosis, to delineate the treatment plan, and to document the results accu“i
CLINICAL
ASPECTS
Many therapists who may be quite adept at writing a meaningful, high-quality record for an individual ptient have major difficulties organizing and satisfactonily recording the wealth of complex, interrelated data obtained in treating an entire family. It is one thing to write a record on a single patient; it is quite another to write one about two adults, usually parents, and possibly several children that portrays each as an individual and yet conveys their complex nuclearand extended-family relationships. If the records are to be meaningful, both individual and family data must be recorded. Two basic questions should be asked to determine if the records will aid in the clinical management of the case and in a possible legal defense: does the chart tell what is happening in the family, and does it justify a particular therapeutic or administrative decision? As an illustration of such a justification, take the case of a therapist who, in the initial sessions, is faced with parents who want to focus only on their symptomatic child. He elects to postpone intensively exploring their marital relationship until later in therapy. He explains in the record that only a minimal marital history was obtained thus far because he felt that therapy might be jeopardized if that area were opened before the resistant parents were ready to discuss it. Specific guidelines for family charts, as well as formats in which to include clinical material, have been established for the department’s recently revised initial family report, progress notes, and closing summary. The formats were designed to be broad enough to be used by most therapists, even those with diverse orientations. Nevertheless, lince any formats on guidelines will reflect, to some degree, the viewpoints of those who Council for Psychiatric Facilities, Accreditation for Psychiatric Facilities, Joint Commission on Accreditation of Hospitals, Chicago, 1972. ‘D. H. Mills, “Hidden Legal Dangers of the Hospital Chart,’ Hospital Medicine, Vol. 1, October 1965, pp. 34-35. ‘Accreditation
Manual
912
HOSPITAL
& COMMUNITY
PSYCHIATRY
developed them, there may be some criticisms. The formats and guidelines are not intended to be the final word on family records, but rather elements that can be modified as new ideas are introduced and experience in using them is gained. Initial family report. This report should contain the name of the family and of the therapist and the dates of the sessions. Under the heading “identifying information,” the names and ages of all family members should be given, as well as their occupations, presenting problems, and source of referral. The next section is “history of presenting problem,” followed by, unless the material is included elsewhere, one on “marital and family history. Under the heading “characterization of family membens,” there should be pertinent information about race, religion, nationality, socioeconomic status, developmental history of each member, the parents’ families of origin and current relationships with them, and personality descriptions of each member in therapy. Under the heading “observations of family system” the therapist should record what goes on in the sessions, both verbally and nonverbally, between family members and between the family and the therapist. Main issues and themes should also be recorded here, as well as feelings evoked in the therapist. A section on “dynamics and treatment plan’ should include the therapist’s understanding of each member, of the family system, and of how the presenting difficulties came about. Psychodynamics, societal, hereditary, and constitutional factors should also be included. The proposed type of treatment-for example, weekly family therapy or chemotherapy-and goals should be stated. Here the therapist may also give a prognosis. Progress notes. These reports should state what is happening with the family relationships as well as with the individual family members in terms of important events in their lives and their emotional states. It should also include dates of therapy sessions, who attended them, how the members interacted, what was discussed, and the therapeutic approaches used. Closing summary. This brief summary of the entire case should include an identification of the family members, the presenting problem, the treatment pnocess, the outcome for the family as a whole and for each of the members, the reasQns for termination, and the disposition. The date of the initial and final sessions or contact should also be included. The essence of these formats is that people are mdividuals in their own right who significantly affect and are affected by their family members. Thus the formats provide for including valuable information about subjective experience and individual psychodynamics as well as a description of the family’s systemic relationships. ‘ ‘
‘
LEGAL Some solely
ASPECTS therapists for clinical
think of a clinical purposes. They
record should
as being realize,
used how-
ever, that any member of the family may at any time become involved in a legal action. Divorce proceedings, child-custody disputes, and certain other civil as well as criminal cases may arise during or after family therapy. In some instances the records may be subpoenaed. What protection do therapists and patients have against having the records opened in court? It is the physician’s or psychologist’s ethical duty to keep confidential the information he has obtained about a patient in his professional capacity. In almost every state, such information is privileged and thus may not be disclosed in a legal proceeding without the patient’s consent. A few states have extended the privilege to psychiatric social workers as well as physicians and psychologists. Regardless of the professional degree of the family therapist or whether he is protected by pnivileged-communication laws, family therapy and family-based necord-keeping raise very special problems and legal issues. Privilege and confidentiality are affected by the type of legal case involved and by the sheer fact that more than one person is involved in the therapy. For example, a husband and wife go to a therapist for marital therapy. One later sues the other for divorce. One raises the issue of mental condition in either the claim on the defense. Most state counts would consider privilege to have been waived. But what if the other party did not want that information to be brought up? Should one member of the patient-family have the right to waive the privilege to the detriment of other members of the family who may either still be in therapy or simply want their communications with the thenapist to remain confidential? That issue has not yet been directly addressed by case law or statute. An argument could be made that the patient is the entire family unit and that each member must waive the privilege before the records can be examined. Although that argument may be used successfully in a divorce case,3’4 its chances of success in a child-custody case are slim because the court’s primary concern is for the best interest of the child. Massachusetts law, in fact, explicitly denies privilege to any therapist in any childcustody case in which either party raises the mental condition of the other party. In sum, a general principle of law is that the court has a right to every person’s evidence. The psychotherapist privilege is a justifiable exception but is strictly constnued and is itself exception-laden. Most important, current law as it relates to family therapy, and records in particular, is at best unsettled. According to Sbvenko, the test of relevancy-not privilege-governs the night to nondisclosure.5 Thus a therapist-family communication is best protected from disclosure by showing that the communication would have no relevance to the issues in the case. Therefore, the therapist should be cautious about Ellis
Slmrln
v. Ellis,
SW. 2d 741 (Tenn. App. 1971). 233 Cal. App. 2d 90, 43 Cal. Rptr. 376. Psychiatry and Law, Little, Brown, Boston,
472
v. Slmrln,
R. Slovenko, p. 67.
1973,
what information he includes in the records. For example, the admission by a husband that he is coming to family therapy sessions to make his case stronger in an anticipated child-custody struggle might best be omitted from the record. If it is mentioned at all, the reference should be a vague one such as Motivations for therapy were discussed. Certainly incriminating or conclusive statements such as The wife is an unfit parent” should be avoided. How detailed the records should be will depend upon the setting in which the therapist works, the family problem being treated, and the type of litigation that could arise. As a final precaution, each adult family member should be asked to sign an agreement that he understands that all of the communications are confidential and that the therapist will not disclose any communication unless all participating members join in the waiver. If each member does sign a release, the therapist must make sure that he did so knowingly and intelligently. But until the legislatures and the courts recognize the need for an absolute privilege for family therapists, this type of written agreement will provide very little protection in the event records are subpoenaed. The lack of an adequate privilege law for family therapists has led some therapists to question whether they should keep any records at all. To be sure, accurate records are the therapist’s best defense against a malpractice suit.6 Perhaps more important, accurate records ensure continuity of care. Nevertheless, many pnivate practitioners keep no charts except the customary record of appointments and billings; others risk perjury by keeping two sets, one to be turned over in case of subpoena and the other for treatment. “
‘ ‘
‘ ‘
PATIENTS’
PRIVACY
In the course of an evaluation or therapy, patients may reveal various intimate aspects of their own or their relatives’ past or current life. They generally do so with the belief that the information will be used by the therapist to help them and will not be passed on to others except in certain situations related to their treatment. To safeguard the patient’s right to privacy, we recommend that certain damaging or embarrassing matenial not be written in the chart. Such material may include the details of sexual difficulties or an extramarital affair. In deciding how much, if any, of such private material should be included, the therapist should balance the need to have complete, useful necords against the patients’ right to privacy. The more private the material is, the stronger must be the clinical reason for writing about it. We have found that an adequate description of the therapy process can be given without including details of exceedingly shameful or damaging material. It is more important to be clear about the strategy and management of the therapy than to be detailed about private matters. Mills,
VOLUME
op. cit.
28 NUMBER
12 DECEMBER
1977
913
