Documenting Safety Protocols for Face-to-Face Psychotherapy Sessions

Documenting Safety Protocols for Face-to-Face Psychotherapy Sessions

Most people agree – change creates upset. Despite the restrictions we experience due to the Covid-19 pandemic, change seems constant. This pandemic will not let us rest in what we already know. Every week or so, there’s something new to learn, absorb, and enact. In-other-words, we’re perpetually exhausted by adjusting to the next change. When the pandemic started, I wrote a blog about how and why to document clinical issues related to the pandemic. Now it’s time for another adjustment.

The Next Documentation Challenge for Psychotherapists

Many clinicians now face the decision of whether and when to return to providing therapy face-to-face. In private practice, this decision is up to the discretion of each therapist. It’s based on the level of risk in your area, the ventilation system in the office building and the level of risk you are willing to incur.

Welcoming clients back into our office means knowing and implementing safety protocols – and documenting them. Since we’re all exhausted, I hope to make this change easier by giving you some guidelines on what and how to document these practices.

Requirements for seeing clients in person.

In many states, the basic requirement for seeing people in person are:

1. both therapist and client wear a mask (or perhaps face shields).
2. the temperature of the client needs to be taken upon arrival.
3. therapist and client must sit 6 feet apart.

Opinions about documenting these requirements.

An August 2020 Face Book poll regarding this question revealed a surprising variety of answers. Some are reasonable though not thorough solutions. Others indicate a disregard for third party oversight that could lead to legal action. Where do you fall in this sample of responses?

• It depends on the client. Some clients are OK not wearing masks in session. Others have tremendous anxiety about contacting Covid-19. So, only document the wearing of masks for those who are anxious.
• If wearing a mask is not relevant to their treatment, then documenting if a client wears a mask is not important. Do we document if a client drives without a license or cheats on their taxes? Where is the line drawn?
• A mask is just another piece of clothing. Unless you document that therapist and client are both wearing clothes, shoes, or underwear documenting whether a client wears a mask is irrelevant information.   
• Documenting the client’s appearance in a mini Mental Status Exam is all that’s needed. It’s the same as noting the client’s appearance.
• Documenting whether a client is wearing a mask, has no temperature and is sitting 6’ from the therapist could potentially be used against either the client or the therapist.
• If mask wearing, temperature taking and sitting six feet apart is clearly explained as mandatory in your consent to treat, then documenting it in every session is redundant. So, no, it’s not necessary.
• Reference the wearing the mask by explaining that reading facial cues is not possible because of mask wearing due to Covid-19 pandemic.

Documentation Wizard Recommendations

Documenting mask wearing, temperature taking, and how far apart we sit is not something any of us ever thought would be part of our lexicon of responsibility. Plus, many therapists resent documenting, in general. So, if adding one more thing to write is too much, I get it!  I often resent the time too.

But it’s important. Here’s why.

Most states strongly encourage temperature taking, mask wearing, and sitting 6’ apart as the safety protocol for in-person appointments. Frances Schopick, JD, MSW, an attorney whose focus is in working with clinicians and a seasoned psychotherapist, suggests that it can be useful to include safety protocols in the informed consent, to have the client review and sign the consent prior to resuming face-to-face contact, as well as to document the fact that you have both followed the protocol in every session. This is for the protection of the client and the therapist.

According to Ms. Schopick, since board complaints don’t have to happen frequently to be highly problematic, it’s worth identifying ways to avoid the risk even if the complaint is ultimately dismissed. Though she is not giving legal advice here, she sides with caution and takes a kind of “belt and suspenders” approach. “While I see what you mean,” says Ms. Schopick, “that the overall informed consent may be sufficient, it could be challenged.”

In other-words, if a client contacts Covid-19, that client could file a board complaint saying the therapist was the point of contact. On the-other-hand, if the client refuses to comply with any of the safety protocols explained in the Informed Consent, the therapist may have grounds to refuse to see the client.

“Someone could claim,” Ms. Schopick continues, “that even though it was in the consent, the protocol was not followed in session. That’s why it might be helpful to have it confirmed each time. A simple checklist can show that the precautions were followed and could be protective if a client claimed you didn’t comply.” These safety guidelines are not laws but they can stand up in court and under scrutiny from our professional licensing boards.

So even though you’re tired, or think documenting adherence to your safety procedure in each session is overkill, or just don’t want to — consider the possible alternatives. Having a record of your agreement and the behavior during each session could save you from a boatload of legal problems.

Make the process easy on yourself.

To make documenting your safety protocols easy, try adding a simple list with check boxes that remind you to follow through with the process and document it. To make it even easier, Documentation Wizard revised the standard Session Note to do it for you. There’s a checkbox for temperature taking, mask wearing (client and clinician) and sitting 6′ apart. Done! This form is selling for $37 but available for a limited time for $27 by using this coupon code MASKUP at checkout.