Three Risk Management Strategies: Documentation, Informed Consent, and Consultation

Pamela H. Harmell, Ph.D., LACPA Ethics Committee Co-Chair



Preparing and maintaining clinical notes provides evidence of the standard of care and that the risk of legal or ethical violations has been managed.  Informed consent, documentation and consultation are three strategies to ensure protection of both patient and therapist. It is not necessary to neglect patient care in order to keep excessive notes that are primarily self-protective. A balanced approach meets both legal and ethical requirements (Remley & Herlihy, 2014).


Record keeping should reflect professionalism and is not the place for personal opinions or reactions. “Records may serve as useful roadmaps for treatment documenting the need for services, the treatment plan, the course of treatment and the process of termination” (Drogin et al., 2010, p. 237). Records should document the nature, delivery, progress, and outcomes of services and facilitate coordination of care (Strum, 2012). Proper documentation facilitates accurate communication with patients and current or future treating professionals.


APA’a Record Keeping Guidelines (2007; 2012) focus on three types of content: (1) General information related to identifying data, history, treatment and intervention plan, fee agreement, informed consent, and release of information; (2) include date, duration, and type of service for each contact, treatment modality, interventions, assessment of current level of functioning; (3) assessment data, crisis management, consultation, and electronic contacts. Documentation helps to assure competent care by demonstrating treatment planning and advantages and disadvantages of options used (Knapp et al., 2013).



Informed consent means “I give you consent to treat me after you inform me of your office policies and what I can expect.” Mandatory informed consent improves patient adherence and commitment to treatment. “Better outcomes can be expected when patient and therapist agree on therapeutic goals and the processes to achieve these goals” (Tryon &Winograd, 2011, p. 50).  Informed consent empowers clients to assist in their own treatment and reduces misunderstandings in office policies, HIPAA issues, billing procedures, and limits of confidentiality. 



Consultation helps ensure best practices and suggests a pattern of lifelong competence-enhancing strategies which include: continuing education, quality feedback, and face to face consultation with peers and experts. Consultation improves one’s personal skill inventory and expands the data base for treatment techniques. Additionally, consultation is the single most effective way to handle counter-transference and burnout while practicing an important form of psychologist self-care (Welfel, 2016).


References are available on request from the LACPA office, [email protected].