Introduction
Professional psychology is considered stricter than most professions because it is held to high ethical conduct. Record keeping in this profession has expectations and standards that should be followed to protect the patient and the psychologist. Psychologists can monitor their work through record keeping when enabled to document their plans and methods of application when providing their services.
A time comes when the psychologist may be required to offer expert testimony, and there are procedures they must also follow. Record keeping ensures they can record informed consent and handle legal aspects that can emerge when assessing records and releasing treatment. This paper will evaluate the ethical issues of keeping records and offering professional testimony.
Ethical Issues of Documenting Informed Consent and Releasing Assessment and Treatment Records
The primary ethical concern connected with the legal aspects of the documents is receiving the patient’s informed consent. Some situations may require sharing assessment and medical records with other caregivers. The informed consent of the patient and the caregiver regarding the release of evaluation and treatment records should be well documented.
The first ethical issue includes the need for a precise enumeration of shared information. Documentation should detail the information being shared, the receiver of the data, and the reasons for disclosing the information (Keshta & Odeh, 2021). There should be proof that the disclosure of information was acknowledged and that no legal procedures were broken by signing a release form.
The second vital ethical issue is that some situations do not need consent to disclose information. Consent is optional when those offering professional services want access to the records and when providing essential expert consultation. The third ethical consideration is that consent is not required when the need arises to protect the caregiver or the client from harm and when requesting reimbursement for services.
Relevant Standards for Disclosing Information and Releasing Treatment-Related Materials
Human relations, confidentiality and privacy, fees and record keeping, and competence are the principles essential to research ethics. Competence is the root of psychological practice because it enables caregivers to identify, accept, and comprehend their depth of information. Boundaries of Competence 2.01 state that caregivers should be specific about having the knowledge to guard their patients (Cherry, 2023).
Confidentiality and privacy are other ethical principles psychologists use when disclosing patient information emerging from treatment. Disclosures 4.05 stresses the necessity of obtaining consent for disclosure from the patient (Cherry, 2023). In addition, ethical standard 4.05 provides guidelines for instances when data can be shared without the patient’s consent.
Code 3.10 of the human relations standards focuses on informed consent. It states that only the legal guardian of a minor can provide consent for treatment and medical information to be shared (Cherry, 2023). Finally, code 6.01 of the record-keeping and fees standards states that all data the caregiver gathers should be understandable (Cherry, 2023). In addition, the data should be stored in a way that can be read and comprehended by those authorized to access it (Cherry, 2023; Keshta & Odeh, 2021). The code also stresses the importance of properly storing and disposing of individual records that are no longer needed.
Example and Rationale
There are instances when patients might feel ethical standards are being violated during treatment. For example, a client can complain that the caregiver is not providing the appropriate treatment due to incompetence. The doctor can provide evidence to the contrary that they are fulfilling the client’s needs based on their expertise (Keshta & Odeh, 2021).
When the doctor provides proof of written documents that the patient was fully informed, the client will receive treatment based on the caregiver’s experience and knowledge in that field. The caregiver’s procedure for documenting the treatment followed the guidelines because the client signed a consent form indicating that information could be shared with third parties. Record-keeping guidelines are also followed because the caregiver can prove that detailed notes are appropriately stored and legible (Keshta & Odeh, 2021). The psychologist can use this information if the client files a claim after the deadline when their information will not be disclosed.
Legal Issues with Evaluation, Diagnosis, and Testing Documentation
Evaluation, testing, and diagnoses concerning expert testimony and record keeping are essential in expert psychology. The legal issues linked to these facets depend on the caregiver’s qualifications to conduct these services, efficient results processing, or whether they use the proper testing tools (Keshta & Odeh, 2021).
First, the professionals need to hold specific certifications before providing services. The absence of official documents supporting the person’s specialization makes the client doubt the legal status of the services they receive. Caregivers lacking proper education and training can establish critical legal consequences if they are involved in expert testimony or manage confidential information. When unqualified professionals are involved in a case, everything is called into question and will jeopardize everything.
The second legal issue connected with the diagnosis is assessing the psychologist’s work objectively. The legal facets and laws regarding assessment and testing are broad but significantly affect ethical practices and standards in testing and evaluation where they exist. Legal issues include illegible, disorganized, and poorly dated files.
Another legal issue can arise when unqualified professionals promote assessment methods. Standard 9.07 does not permit unqualified individuals to score, distribute, or interpret psychological evaluations (Keshta & Odeh, 2021). When assessments are misused, they harm social, legal, diagnostic, and educational policy decisions that lead to incorrect and deceptive information.
Caregivers should not allow individuals who want the results to be in their favor to interpret the tests, as it would result in legal issues. According to code 9.11, caregivers must protect and maintain the integrity of testing tools (Keshta & Odeh, 2021). They should also not violate code 9.06, which handles the importance of tests (Keshta & Odeh, 2021). Another legal issue is psychologists’ inaccurate diagnoses of patients for third-party payers like insurance organizations. This behavior violates code 6.04b, which deals with financial arrangements and fees, as it constitutes insurance fraud.
Examples and Rationale to Support Legal Issues
The rationale for supporting legal issues is based on the need to protect patient’s health and personal information to ensure a high-quality approach to medical services. An instance of improper assessment is when the caregiver carelessly records judgmental thoughts or initial expressions about the patient, disregarding how information can be misinterpreted in legal proceedings. The proposed action is to hire individuals with the formal training, experience, and education, as stated in standard 9.07, to interpret, score, and administer tests necessary for competence trials, treatment plans, or parenting skills (Keshta & Odeh, 2021).
Another example is when the caregiver uses test specifics to interpret test results in legal proceedings in their favor or to lower the value of the test. The proposed action is for the attorney to collect actual data from the assessment and inform the judge or jury that the caregiver has provided a misleading interpretation that has hurt the client (Keshta & Odeh, 2021). Finally, an example of legal issues arising in patient diagnoses is when the caregiver changes the patient’s diagnosis to fit a situation that an insurance company covers. The recommended action is to report the psychologist to the relevant authorities, as it is considered fraud.
Conclusion
Psychologists protect themselves and their clients while maintaining high professional standards. A trusting and robust relationship between the caregiver and the client can be achieved by comprehending the necessity of ethical requirements regarding expert testimony and record keeping. The knowledge of the legal expectations will benefit the relationship between the client and caregiver and ensure the doctor proceeds to assist those who require it.
References
Cherry, K. (2023). APA code of ethics: Principles, purpose, and guidelines. VerywellMind. Web.
Keshta, I., & Odeh, A. (2021). Security and privacy of electronic health records: Concerns and challenges. Egyptian Informatics Journal, 22(2), 177-183. Web.