Community Mental Health and Wellness Recordkeeping

Running head: Community Mental Health and Wellness Recordkeeping
Community Mental health and Wellness Recordkeeping
Name of the Student
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1Community Mental Health and Wellness Recordkeeping
Contents
Section 1: Client Rights and Informed Consent.........................................................................2
Section 2: Client Record Keeping..............................................................................................3
Section 3: Electronic Medical Records......................................................................................3
References:.................................................................................................................................6

2Community Mental Health and Wellness Recordkeeping
Section 1: Client Rights and Informed Consent
According to the Joint Commission, Informed consent can be understood as an
“agreement or permission” followed by a complete notice regarding the care, treatment or
service provided to a patient, which is the subject of consent (Faden et al., 2014). Information
regarding the nature, risks and alternatives to a clinical process or treatment or service should
be shared with the patient before proceeding with the process, allowing the patient to provide
an informed consent on whether to proceed with the clinical processes or not. The process of
informed consent starts with the communication between the patient and the healthcare
professional (like a physician) and ends with the patient either giving authorization or agrees
to go through a specific treatment or clinical process (Gardy, 2015). During this process the
professional should:
i. Make assessments about the ability of the patient to understand medical information
relevant to the clinical process or patient’s condition as well as the alternatives to the process
and their implications in order to make an informed, voluntary and independent decision.
ii. Share relevant information with the patient with both accuracy and sensitivity, keeping in
mind the patient’s preferences towards receiving clinical information and the rights towards
privacy. The professional should also share information regarding the diagnosis, the nature
and purpose of intervention, the risks/burdens/benefits as well as the (approximate) costs and
billing procedure of the proposed and alternative treatment options.
iii. Documenting the conversation leading up to the informed consent in the medical records,
along with the filled up consent form.
(Joint Commission, 2016)