When you decide to seek clinical consultation, there are 5 things that you should document in your clinical notes. They are the 5 W’s:
- When you seek consultation;
- Why you are seeking consultation and why now;
- Who you are seeking consultation from;
- What opinions / information / recommendations you are receiving from that person even if they contradict your own clinical judgment;
- What your final professional opinion / plan is and why you are / are not going to go along with the recommendations received.
"Questions" by Tim O'Brien / Oberazzi
In other words, your clinical rationale all along the way needs to be documented in your notes. Why? To protect both you and your client.
Should you end up in a malpractice suit (which is quite possible), your proper documentation will assist you in explaining your thought process concerning your work with your client. Likewise, should anything happen to suddenly prevent you from continuing to work with your client, your general direction of treatment can more likely continue seemlessly because you have taken the time to thoroughly document your clinical rationale and intent.
[...] your clients? No. What it does mean is that you need to do so after careful consideration, consultation, and only after obtaining fully informed consent from your client. In my next post, I’ll [...]