Maybe you've taken my challenge to review some of your documentation from the last year or so and found that there are a few things you'd like to change... but how the heck do you do that?!
Is it okay to change a case note after you've written it? What if you realize you left out something really important? What about forms... you'll likely change your policies at some point in time. What does that mean for the people who signed your intake forms last year?
Have no fear because after three years working in quality improvement/quality assurance, I'm sort of a pro in helping people correct their records... and yes, there's a right and a wrong way to do this! However, as is usually the case, the specifics depend on the circumstance. (I know, people hate hearing me say that all the time, but these things are rarely black and white)
So, let's go through a couple scenarios... the first one is the most common. Let's say you receive notice (from a client, your licensing board, a lawyer, etc.) to release some of your records. Because you're a responsible and conscientious therapist you go through your notes to review everything. While you may be responsible and conscientious, you're also not perfect... so you notice a few things are missing or just don't provide the right picture.
Is it unethical to change or add to a note to provide more detail? Absolutely not... as long as you identify that note as a change. If you're using paper records, just write underneath your signature or the bottom of the note, "Addendum" and add your other details or explanation along with the current date and your signature.
If you're using an electronic record, the system should allow you to write an "addendum" note attached to the original note. If you're not sure how to do this shoot their helpdesk an email. In the off chance they don't offer this option... 1) Give them feedback that they need to include this as an option and 2) Write a new note with an entry on that same date. Identify it as an addendum note at the top "Addendum to case note on 01/27/15" and write your other info.
But what if it's more than just one note or one date you want to change? That could be a lot of time to go through each one! In that case, start a new note with today's date and write "Records Review" or "Case Review" at the top. Then include any information you feel is missing from the file in general or any info you think needs to clarify something that relates to more than one date. Now you've made sure this file is awesome and it didn't even take you that long!
The key here is to remember that documentation is a fluid process, just like therapy. There are no unforgivable mistakes or things that can't be explained later on down the line. And you can always add information at a later time without compromising the notes you previously wrote.
I hope this gives a nice option to avoid changing notes you've previously written. I never recommend doing that... the addendum is usually the best, most ethical choice to make sure your notes are up to par.
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