1. Do I need to have the client sign the informed consent document?

Answer: It's a very good idea to do so. If the clinician should be challenged llegally, a signed informed consent shows the the client accepted the conditions for treatment set by the clinician.

2. How much should I write in my mental health records?

Answer: Create a balance between documenting the necessary information to document assessment, diagnosis, and treatment with the assurance that you are writing enough information to avoid forgetting important details.

3. What is the difference between progress notes and process notes?

Process notes are used by the clinician to explore tranference and countertransference issues that arise in the course of treatment. These are rich in emotional material. Progress notes establish the progress of treatment. This includes assessment, diagnosis, and treatment protocols, which include documentation of how the clinician addressed crisis issues and processed them. both are legal components of treatment records and are subpoanable.

4. I've heard that the informed consent document isn't that important. Is that true?

Let me tell you what the attorneys whom I have worked with have told me. They love to sue clinicians who haven't provided informed consent to clients. First, it's a legal requirement to do so. Next, if the client's hasn't been informed in advance of the expectations of treatment, the opposing attorney will hold clinicians accountable for injuring the client, being unprofessional clinicians, and for failing to carry out their professional duty. Based on how opposing attorneys like to hold clinicians accountable when they haven't provided informed consent to the client, I would say this is important.

5. Is it true that I can write my notes with pencil?

I don't recommend it. If I were examing your records as an expert witness helping an opposing attorney, we would use the fact that you wrote your notes in pencil to show the court that your intention was to alter your notes if something went wrong. I ask you: "Why take that chance?" Instead, I recommend that you use a pen to write your notes.

6. Is it true that clinicians aren't required to use informed consent? 

I've reviewed publications written by important attorneys in California. One of them, Brent Caudill, clearly states in his book about California Mental Health Law that he considers the use of informed consent a requirement. Let me ask you: "If Mr. Caudill was the opposing attorney in a case against you, what would be your view about using informed consent?" I ask you this because he will likely question the clinician whether he/she used informed consent and the corresponding reason.

7. I use computerized notes. Are there any problems I can run into?

8. I'm a drug and alcohol counselor and I'm having trouble defining how "reasonable suspicion" applies to me. Can you help?

Federico C. Grosso, DDS, PhD, MFT, BCFE
Board Certified Forensic Examiner
Licensed Marriage and Family Therapist
Expert Witness in Malpractice and Administrative Actions
Involving MFTs, LCSWs, CADCs, and CATSs.