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Digital Seminar

Documentation and Risk Management in Behavioral Health: Top Ethical Challenges

Frederic G. Reamer, PhD
Approx. 6 Hours
Aug 02, 2023
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Media Type:
Digital Seminar - Also available: DVD | Live Webinar

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Sometimes regarded as a “necessary evil,” the reality is that the quality of practitioners’ documentation often determines the outcomes of lawsuits and licensing board complaints filed against practitioners.

Skilled documentation that is consistent with ethical standards can ensure you are providing quality services to your clients and often leads to positive litigation and licensing board decisions. Skilled documentation can also save you valuable time.

In contrast, poor documentation can be disastrous when introduced as evidence in court and licensing board proceedings.

Watch Dr. Frederic Reamer, a leading author of books and other publications on risk management and documentation in behavioral health, as he draws on his extensive experience as an expert witness for more than 30 years in litigation and licensing board cases throughout the United States.

Dr. Reamer will provide a comprehensive overview of:

  • State-of-the-art documentation standards
  • When to be vague and detailed in clinical notes
  • The advantages and disadvantages of short and long notes
  • Key ethical issues and standards related to documentation in behavioral health
  • Challenges when using electronic records
  • Relevant statutes, regulations, and case law
  • Common documentation mistakes
  • Practical documentation strategies to protect clients and clinicians
  • And much more!

Too often practitioners’ documentation exposes them to considerable risk related to audits and lost revenue. Documentation is an essential element of behavioral health - don’t let the “necessary evil” affect your practice and clients.

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CE Information Coming Soon

Continuing education credit information is coming soon for this non-interactive self-study package.

CEs may be available for select professions, as listed in the target audience. Hours will be dependent on the actual recording time. Please check with your state licensing board or organization for specific requirements. 

There may be an additional fee for CE certificates. Please contact our Customer Service at 1-800-844-8260 for more details. 

**Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of mental health professionals. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards.


Frederic G. Reamer, PhD's Profile

Frederic G. Reamer, PhD Related seminars and products

School of Social Work, Rhode Island College

Frederic G. Reamer, PhD, has been a professor in the graduate program of the school of social work, Rhode Island College, Providence, Rhode Island for 40 years. Dr. Reamer received his PhD from the University of Chicago and has served as a social worker in correctional and mental health settings. He chaired the national task force that wrote the National Association of Social Workers Code of Ethics and served on the task force that added technology standards to the code. Dr. Reamer lectures both nationally and internationally on the subjects of professional ethics, professional malpractice and liability, and documentation. In addition to ethics, his research and teaching have addressed a wide range of human service issues, including mental health, health care, criminal justice, and public welfare. Dr. Reamer has conducted extensive research on professional ethics and has been involved in several national research projects sponsored by The Hastings Center, Carnegie Corporation, Haas Foundation, and Center for Bioethics of the University of Pennsylvania. Dr. Reamer has been an expert witness and formal ethics consultant in more than 130 litigation and licensing board cases throughout the United States. He is the author of many books and other publications on ethical standards in behavioral health, risk management, and documentation.


Speaker Disclosures:
Financial: Frederic Reamer has employment relationships with the Rhode Island College, the Rhode Island Department of Corrections, and the Providence Police Department Training Academy. He receives royalties as a published author. Frederic Reamer receives a speaking honorarium and recording royalties from PESI, Inc. He has no relevant financial relationships with ineligible organizations.
Non-financial: Frederic Reamer is a member of NASW Code of Ethics Revision Task Force and the National Association of Social Workers.

Additional Info

Access for Self-Study (Non-Interactive)

Access never expires for this product.


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  1. Identify the diverse purposes of documentation.
  2. Address documentation challenges related to client privacy, confidentiality, and privileged communication.
  3. Identify the implications of skilled documentation for risk management in behavioral health.
  4. Avoid common documentation mistakes.
  5. Develop documentation protocols consistent with ethical standards in behavioral health.
  6. Implement ethics-informed documentation strategies to protect clients and prevent lawsuits and licensing board complaints.


The Role of Documentation in Behavioral Health
  • Effective client assessment
  • Planning and delivering services
  • Accountability to third parties
  • Continuity and coordination of services
  • Supervision of clinicians and staff
  • Evaluation of services
Policies and Protocols for Documentation Challenges
  • What to document and what not to document
  • Language and terminology
  • Use of electronic health records
  • Ways to enhance credibility and mistakes to avoid
  • Access and disclosure of documents to clients or third parties
  • Record retention
Ethical Standards
  • Privacy: Protecting client information in records
  • Confidentiality: Disclosure of protected health information
  • Privileged communication: Disclosure during legal proceedings
  • Informed consent: Consent to treat
  • Defamation of character: Preventing libel and slander
Ethics Informed Documentation Strategies
  • Vague documentation v. detailed documentation
  • Long notes v. short notes
  • Decisions about third-party access to records
Documentation and Risk Management: Malpractice and Licensing Board Complaints
  • The nature of malpractice: Documentation issues
  • Malpractice and licensing board risks related to documentation
  • Standards of care in documentation
  • Acts of omission in documentation
  • Acts of commission in documentation
  • Responding to subpoenas
  • Documentation challenges in the digital age
Practical Tips on the Do’s and Don’ts of Mental Health Documentation
  • Examples of good and bad notes
  • Case examples

Target Audience

  • Counselors
  • Social Workers
  • Psychologists
  • Addiction Counselors
  • Physicians
  • Marriage & Family Therapists
  • Psychiatrists
  • Behavioral Health Nurses
  • Case Managers
  • Mental Health Administrators
  • Office Managers
  • Other Mental Health Professionals


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Your satisfaction is our goal and our guarantee. Concerns should be addressed to: PO Box 1000, Eau Claire, WI 54702-1000 or call 1-800-844-8260.

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