The May Lunchtime Specialty Practice Sections Teleconference, highlighting documentation in private practice, proved to be a popular topic with social workers.

Nearly 1,000 people registered to listen to the live teleconference hosted by NASW Senior Policy Associate Mirean Coleman.

The teleconference was one of several launched earlier this year exclusively for NASW members to give them an opportunity to earn 1.0 continuing education units (CEUs) upon successful completion of an online test following each event. Participants can also listen to or read a transcript of each topic in the series at any time.

Regarding the teleconference on documentation, Coleman said it is an important tool in private practice. "Documentation reflects the ongoing professional activities of the clinical social worker, from the initial patient interview through the termination of psychotherapy services," she said.

"It also indicates the quality of care that a patient receives, and it protects not only the clinical social worker, but also the patient in the event of litigation," Coleman explained. "It verifies also that the services were performed and if they were necessary and appropriate."

Clinical social workers also should be familiar with the documentation requirements of their state statutes, state licensure boards, accreditation bodies and third-party payers.

Coleman explained that even in the event that a patient pays for services with cash, documentation is still important. In her presentation, Coleman went over a list of procedures for keeping records.

"It's always best to develop a policy and procedure manual for your practice," she said. "This would include policies of your practice such as emergency coverage and coverage when you're away from the office, your fee schedule and your cancellation policy."

Coleman pointed out that electronic records are being used more frequently by clinical social workers, and because of this, they should be aware of the requirements and special safeguards needed to protect electronic patient health information.

Coleman also described different documentation methods.

"The best documentation format is to use one that allows flexibility and is open-ended, one that allows the freedom and space geared toward the individuality of a therapy session," she said. "Many consider a combination of both the free-form format and the preprinted form as the best practice."

Coleman also discussed documentation recommendations for clinical supervisors as well as best practices for storage and retention of documents. She noted that NASW has several resources for documentation, including Health Information Portability and Accountability Act (HIPAA) forms that can be downloaded from HIPAA Help for Social Workers.