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Protecting Clients Through Better Notes: An Interview with Dr. Maelisa McCaffrey

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Protecting Clients Through Better Notes: An Interview with Dr. Maelisa McCaffrey

Curt Widhalm and Katie Vernoy talk with Dr. Maelisa McCaffrey about how therapists can ethically and effectively document in a politically charged climate. They discuss how to navigate sensitive topics such as gender identity, reproductive rights, and immigration status while maintaining ethical, accurate, and protective documentation.

Transcript

Click here to scroll to the podcast transcript.

(Show notes provided in collaboration with Otter.ai and ChatGPT.)

About Our Guest: Dr. Maelisa McCaffrey

Dr. Maelisa McCaffrey is a licensed psychologist, nail design enthusiast, and author of the book, Stress-Free Documentation for Mental Health Therapists. Through her business QA Prep, she empowers therapists with training and consultation on clinical documentation. Maelisa focuses on the “why” behind the usual recommendations and encourages clinicians to think outside the box, while also keeping their ethics intact. As someone with ADHD who’s had to figure out what works through trial and error, Maelisa aims to make sure her trainings are practical, while also allowing for plenty of laughter and fun.

In this podcast episode: Ethical and Protective Documentation for Therapists

Curt and Katie are joined by Dr. Maelisa McCaffrey to talk about how therapists can document client information responsibly and thoughtfully in uncertain times. They explore how to talk with clients about documentation, how to protect client safety, and what to include—or leave out—when working with politically sensitive issues.

Key Takeaways for Therapists on Ethical and Protective Documentation

“You can only do the best you can with the information you have available at the time.” — Dr. Maelisa McCaffrey

Therapists are facing new concerns that documentation could put clients at risk, especially around gender identity, reproductive decisions, or immigration status.
Informed consent is essential—clients should know what is written, why it’s written, and who might access their records.
Write accurate yet sensitive notes that prioritize client safety while maintaining clinical integrity.
Use neutral, clinically meaningful language (e.g., “pregnancy loss” instead of “abortion,” “identity questions” instead of “gender transition”).
Engage clients in conversations about their preferences without shifting the responsibility for safety onto them.
Focus on therapeutic themes—grief, safety, values, identity—rather than charged terms.
Reevaluate intake forms and informed consent practices; include only what’s truly necessary.
Accept that documentation will never be perfect—your ethical intent and transparency are key.

“If it’s in the record, think about why.” — Dr. Maelisa McCaffrey

Resources on Ethical and Protective Documentation

QA Prep: www.qaprep.com
Stress-Free Documentation for Mental Health Therapists by Dr. Maelisa McCaffrey — QA Prep Book Page
QA Prep trainings and consultation services for mental health professionals
Follow @qaprep on Pinterest, YouTube, and Facebook

Relevant Episodes of The Modern Therapist’s Survival Guide

Meet the Hosts: Curt Widhalm & Katie Vernoy

Curt Widhalm, LMFT

Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com

Katie Vernoy, LMFT

Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com

A Quick Note:

Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.

Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.

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Modern Therapist’s Survival Guide Creative Credits:

Voice Over by DW McCann https://www.facebook.com/McCannDW/

Music by Crystal Grooms Mangano https://groomsymusic.com/

Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):

Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements)

… 0:00
(Opening Advertisement)

Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide, where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.

Curt Widhalm 0:13
Welcome back modern therapists. This is the Modern Therapist’s Survival Guide. I’m Curt Widhalm with Katie Vernoy, and this is the podcast that is considering changing its name to the uncharted territory podcast. A show that would help therapists navigate the wild, untamed frontier of modern day practice. We’re talking about a whole new frontier that we’re dealing with documenting our clients, deepest, most personal concerns in a political climate that feels a little bit less than friendly these days, if we’re trying to sugarcoat things here from the top of it. So we’re really talking about when a client shares their struggles about such things as LGBTQ plus issues, abortion access issues. It’s not just a clinical issue anymore. It’s a legal one. We talked about this a couple of years ago in documenting in multi state situations, knowing all of the different states. Now we’re rolling it out nationally, and a episode is really about how that this be used against my client in court and helping us dive into this today is our good friend, Maelisa McCaffrey, thank you so much for joining us and sharing your expertise on how the hell we document things these days.

Curt Widhalm 0:16
Thank you. Happy to be here, not necessarily happy to talk about the topic, but also happy to talk about the topic. Let’s, let’s get into it.

Katie Vernoy 1:46
It’s so good to see you and have you back on the show. We’ll link to all you know, the other episodes you’ve been on in the show notes over at mtsgpodcast.com. But before we get into this, let’s have you answer the question we ask all of our guests, which is, who are you and what are you putting out to the world?

Dr. Maelisa McCaffrey 2:00
Yeah, I am an ADHD, like not rule-loving, super, not type A person, who teaches other therapists how to document. And that is as in conflict as it sounds, right. And so, because documentation, details, specifics, even to some degree, rule following is not my go to thing, I had to get really good at it very early on in the profession, and over time, created a business called QA Prep, where I helped mental health therapists with their documentation, and found out it was a really big need, and it has blown up. And I love it, and I’ve been talking about documentation for 12 years now, which is crazy, and I literally had a new thing come up, like I created a new template yesterday. That’s how, how crazy some of this stuff can be in that it takes that long of obsessing over these things and doing this literally full time. You know, I do this full time, and I just created a new template strategy yesterday. So if you’re struggling with documentation, and it hasn’t been your full time job for 12 years, it’s understandable. But yeah, that’s so that’s me. And so I have been getting a lot of questions about documenting sensitive and politically charged topics much more so the last six months, but it has been a concern, I think, since Roe v Wade, and since states started having different abortion laws, and people are now commonly licensed in more than one state. And so I know you guys had another episode where you kind of talked about that, and that’s that’s really where I think between that and then dealing with teenagers and LGBTQ and specifically transgender identity issues as well. Those used to be the more common questions, and now I’m getting questions about all kinds of things from people’s legitimate concern.

Curt Widhalm 4:16
What are the fears and questions that you are getting?

Dr. Maelisa McCaffrey 4:20
I’m getting questions about, obviously, transgender status. I would say that question used to be a lot more specific to working with teenagers and being concerned about, like, you know, could someone’s parents or guardians access their records, and what might happen if, if you keep that information secret, good and bad, right? And now I get that question for people who are adults, right? Because it used to be, I could say, well, you know, if, if you have a queer client and they’re 25 years old, they get to decide what they’re going to do with their records, and you, you just, you know, work with them on that, right? And you just kind of inform them. Now I’m getting questions about: How like should I document that my, you know, 40 year old client is in a lesbian relationship. You know, specifics like that that weren’t a concern before. Other questions about things like immigration status and do I need to have, you know, do I need to have an ID on file, and what are the rules around this, and can I document it? Should I document it? And I think the biggest thing is that a lot of these issues, immigration status, considering an abortion, having some type of a like a queer identity or lifestyle, these are all things that clients talk about in therapy a lot, right? So it’s not like something where I can give you one phrase to use and then you can just use that once and you never have to address it again. You know, if you are talking with a teen, for example, you might be discussing their transgender identity and their struggles around that every single session. And so it’s not, it’s both something that we want to, you know, protect our clients from harm as best we can and like we can’t just lie and pretend that these things are not in existence. And I would even argue that to pretend that some of these things don’t exist is, is a disservice in some ways, to some clients, right? We don’t want to minimize that this is an important issue to them. And we want to think through what are potential consequences? I will say those potential consequences, that’s another question I get a lot is, you know, I’ve always gotten the question, how much is too much in a progress note, and, you know, should I, am I writing too much, or am I writing too little? That’s probably one of my first blog posts ever, right? And, and I’ll probably always get that question, and that applies across the board. But now it feels like the stakes are much higher, because they used to be, well, my client, you know, for example, did something. They were driving drunk and gotten in an accident, and then talked to me about it. Can I document that? Right? Is that too much or too little? And it used to be thinking through consequences like that for people. Now it’s thinking ahead to I’m seeing trends in the world or in the country or in my state, and I don’t know if the environment might be different in a year, in six months, and I’m also getting questions about now the environment is different in my state, especially, and should I go back and change documentation? Should I go back and change what I wrote last year, because last year I wasn’t worried about this, and now I am. So those are the common questions that I’m getting, or how much detail, what phrases to use, do I change my documentation?

Katie Vernoy 7:56
It seems like documentation is one of those things that has been the bane of therapists existence for all time. And I even remember my, one of my first supervisors said, write very little, and I haven’t written a note for years, and I’m gonna, if I get, you know, my records subpoenaed or whatever, I’ll just make it up, you know, and…

Dr. Maelisa McCaffrey 8:21
Which is not a strategy we recommend.

Katie Vernoy 8:23
No, it’s a horrible strategy. It was a horrible, horrible strategy. But I think it’s something where there was that element of, I’m going to scribble my notes. I’m going to write very little, and I think there’s that end of the spectrum, all the way to my documentation is a bill. I need to have the, you know, medical necessity and all of the things that are going to help me bill like Medicaid or those types of things. And I need to remember things, so I need to have all of these things here and so much detail. And it it feels like, it just feels impossible to navigate at this point, because if I put something in my notes that I don’t remember what it means, or I don’t remember what happened in the session, I think that is a disservice to clients. But if I put too much information and documentation is subpoenaed or just commandeered, or whatever, my client could really be at risk. And so what is the advice that you’re giving at this point? We’ve got kind of previous Maelisa’s advice around the clinical loop and all the things so good documentation. We’ve got, we’ve got that covered. We’ll, we’ll put that in the show notes. But I think there’s this almost strategic defensive documentation that we’re talking about right now.

Dr. Maelisa McCaffrey 9:46
Yeah, and I’m glad you asked it that way, because I have been pretty open about saying I have changed my advice very recently, and used to think about this a little bit differently. And I, I would hope that others can see that as professional development, and like we all have to adapt. Anyone who’s been in the field for 30 years can tell you, everything is different than it was 30 years ago, right? That’s that’s going to happen. So that’s not bad in and of itself, but, you know, to get really existential about it. I used to see kind of like your supervisor’s experience. I used to view that, and I think that’s because of a lot of the mentality behind that, I’m assuming that supervisor wasn’t saying that because they just felt stressed and didn’t want to write notes. It was like almost this elitist attitude of I know better than whatever entity is coming in. How dare they question me? I don’t need to give them what they want.

Katie Vernoy 10:46
Exactly.

Dr. Maelisa McCaffrey 10:48
My clients don’t need to see that. How dare you know HIPAA exist and my clients potentially have access to their records. That was a very common mindset, and I think still exists in some circles. And I have always very much rejected that idea and really taken the view that regardless of the entity, so I I’m agnostic, I say about insurance, right? So if you want to use insurance, there’s good reasons to do it. If you don’t want to use insurance, there’s good reasons not to use it. So I, you know, would never fault anyone, either way, as a therapist, for accepting or not accepting insurance. But if you do, like you have to acknowledge the reality of you’ll need to document more, and you’ll need to document certain things. That’s that’s just the reality. I don’t think it needs to be extreme. But ultimately, all of these issues, we tend to get very hung up on our own beliefs, our own feelings about it, and honestly, that matters very little. What is the most important is informed consent. That’s always been the most important, the fact that, like your clients, should know that you document that should not be a question. And if you have clients in any of these sensitive or politically charged scenarios, if you have clients who are kids or teenagers, right, anything where that, if you see couples, anything where the fact that you are documenting things can be a little bit more high stakes than for the kind of average, right, individual with depression. That should be something that we’re talking about with people.

… 12:31
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Curt Widhalm 12:32
What is, what does that conversation look like? Because…

Dr. Maelisa McCaffrey 12:35
Yeah.

Curt Widhalm 12:35
I think the there’s a lot of things, especially working with teenagers, where you can say, look, I want to have this very upfront conversation that I’m going to be documenting things. And this could get really scary for you in teenage brain, going, yeah, yeah, whatever. I click on all kinds of terms to service without reading through them, and I’m totally, you know, 18 on the internet for lots of things, and not really having beyond adolescent brain and thinking about the consequences. So even, how does that conversation look like?

Dr. Maelisa McCaffrey 13:06
Yeah, exactly. So I think it the first session. It may or may not be a big deal for people, right? And that’s the thing, like the insurance conversation, right? I always say, like you need to tell people that you have to give them a diagnosis. You should never give someone a mental health diagnosis and let them, without them being aware you will do that, right? And some people are like, Yeah, okay, whatever. Like, they really don’t care. For other people that is like, full stop, well, what are we doing here? That’s a big deal for them. This, in that vein, this is the same discussion. So for a kid who’s transgender, there are kids whose families are aware, whose families are supportive, you’re still gonna have the same conversation with them, right about, like I would just want you to know I have to take notes. I’ll be taking notes about things, if you ever have questions about them, obviously, depending on your state and the age of the kid, and what the various laws are there, but usually you can give the kids access when they’re in that adolescent range in most states. you know. You can say you can, even if you can’t, even if you’re in a state where, like, adolescents don’t have any rights to their records and you have to be 18, you can still say, you can always ask me about what I’m going to write. You can always ask me about what I might say, and then I think, then you you see where, where the person is, right? So whether that’s an adult, whether it’s a teen, it doesn’t really matter. You see where they are and how they respond and whether or not they care. And then if the person doesn’t care, great, like, Don’t obsess over something that they don’t care about. Right? Move on to the other relevant informed consent things that you’ve got to talk about with people, but remembering that informed consent is not intake, it is not a form, it’s a process, and it’s a process that we have throughout therapy with people. And that means it might come up again, and a lot of us have had this happen where it’s six months in, someone shares something with you, and you’re like, oh, oh, man, I have to write a child abuse report, or you’re working with a kid, and you’re like, Oh, crap, I might actually have to talk to the parent about this one, right? And that’s where to maintain the relationship and to practice informed consent, then you have that conversation and session about, you know, I’m a little concerned about this for whatever reason. Or, you know, I want you to know, I’ll have to, I’ll have to make this report, I’ll have to talk to this person, or I’ll need to consult on this topic, right? Whatever that might be, it’s making sure that you inform people that’s what’s going to happen. I think what takes this to the next level, in this, in our current circumstances, is potentially when you, when you have that uncomfortable feeling when you’re going to write something down, or you, if you’re using AI, you see the way the AI wrote something for you, if you’re like, uh, I don’t know if that sounds right, or, Oh, I don’t know if I should be writing that, or if I should put that down on, like, actually document that word or that phrase or that thing, I would trust that gut feeling. And if you are in a place where you kind of doubt your gut feeling, or you kind of trust the gut feeling, but you’re like, I don’t know if this my stuff right? You know, then consult with somebody about it, or listen to this podcast, or watch one of my YouTube videos, right, you know, but get some support instead of just ignoring that feeling. And so my recommendation is always that if that first feeling happens and the client is you’re either able to talk to the client about it before you finalize that note, or you or if you have a supervisor, or if the client is there, and you’re kind of thinking about, like, oh crap, how am I going to document this? Talk with the client first. Right? And say, like, hey, you know, I’m wondering if you know, I’m thinking about the fact that you know that I write notes and I’m thinking about how I need to document this. Do you have any preferences? It doesn’t mean that you have to do what the client is going to say, because we can’t always promise to do that. So never promise to do that. But I do think it’s relevant here when we’re talking about LGBTQ issues, when we’re talking about even immigration status, I’m even thinking of, you know, people who are citizens, but maybe have members of their family who are not citizens, right? You know, ask them, How would you like me to describe that? How would you like me to write that down? Do you have feelings either way about how I write that down, or I commonly use this word. Does that apply to you? And I think that as a field, we have gotten more sensitive to doing that in general with things like pronouns. 10 years ago, like pronouns in intake paperwork were not really as much of a thing as they might be now, right? That’s one example of, I think, how, as a field, we have adapted to start to do that and be a little bit more open with, not only what are legal definitions of things, but how do people want to be described? How do people want to be addressed? And so, viewing it in that way, and talking with them about, you know, for abortion, for example, like I usually recommend just using the word pregnancy loss, because that gives you the freedom to still discuss all the issues that are related to abortion that people commonly have. And some clients might it might be one session. It might be a one off thing. For other clients, it might be a devastating topic, right for a variety of reasons, or for some clients, it just might be a big topic of discussion, and you want to be able to address it. And so if you say pregnancy loss, that is real, like you’re not lying there, that’s what happened. And it it accurately, kind of reflects the the level of grief and depth of things that can happen. And I think more accurately aligns with the types of things you’re likely to document about that session. But ask your client, you know, I usually use the phrase pregnancy loss when we talk about abortion in a therapy session. Do you have any feelings about that? Do you have any concerns about that? Do you have any preferences? And see what clients have to say. I do think where this is also similar to the insurance conversation of some clients really, like, don’t care, right? And they’re just like, you know, like, the diagnosis thing, they’re like, Yeah, okay, whatever, just give me a diagnosis. I don’t even care. I don’t even need to know. And part of our professional role is to think ahead a little bit, and so don’t get conspiracy theory with your clients. But you know to say, like I have seen, or I have heard in a training that you know, this could potentially be a negative if this word is used. So I prefer to say pregnancy loss over abortion, right, just as an example. So if your client doesn’t care that also doesn’t give you carte blanche to just write everything. I would say, still use your professional judgment to try and document accurately but sensitively. I also tell people focus less on the buzz words and more on the gen the general topic, right? So, like abortion, that’s that’s the buzzword, that’s the the politically charged word, but the issues, the feelings, the discussions around it, that’s often about grief, it’s often about religious beliefs, it’s often about desires and wants, and it’s often about disagreements with a partner, right? It’s all of those things and those things you can document accurately.

… 20:48
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Katie Vernoy 20:48
I like a lot of this. There’s, there’s a part of this that feels a bit uncomfortable to me, and I wanted to put that out there, because I think there’s some advice that I need, and also maybe, you know, a different perspective to share. When I think about talking to my clients about documentation, I feel like it has a similar flair to some of the ways that I’ve talked about child abuse reporting. And this is what my responsibility is da-da-da-da-da, and this is, if you’re talking about this, this is what’s going to happen, and this is how all of that’s going to be and this is how and potentially, this is how it might be documented those types of things. And I feel like it is informed, and I feel like there’s a part of this that then leads to clients not feeling able to talk about the things that they really need to talk about in therapy. I also feel like in asking them how they want their work to be documented or having that conversation in more depth, it puts a different pressure on them to try to understand it. It may increase their anxiety. It’s something where my default is, I’m cautious. I’m talking about the underlying issues, not the buzz words. I like that. That’s a really good piece of advice. I like that. I think that’s kind of what I’ve been doing by nature, but, but it is something where it does add a responsibility to the clients, and it potentially may have the clients not feel completely safe to talk about all the stuff that they want to talk about in therapy.

Dr. Maelisa McCaffrey 22:18
Yeah, I think that’s a really good point. And I think that’s why you do gadge, like, how interested they are in it, how concerned they are, obviously, and use your professional judgment in when and how you bring it up, right? And that’s why I do say, like, don’t get conspiracy theory with people and start going to all the worst case scenarios, because we can never predict all of those, right? And we’re not doing that when we talk about child abuse reporting, even though that can be a really big deal when that does happen, right?

Katie Vernoy 22:46
Sure.

Dr. Maelisa McCaffrey 22:47
Instead, I would say, you know, most of the people who most of the therapists who are coming to me with these questions are coming to me, this is where it’s important to look at, what are my feelings and what are my clients feelings.

Katie Vernoy 23:01
Yeah.

Dr. Maelisa McCaffrey 23:01
So like, if your client is talking about being super terrified under the Trump administration and literally hiding or not feeling like they can go to work because raids are happening in their city, or they know someone who, you know, who was taken right? If that is happening, that means they are concerned about it. And so I would say kind of, I agree with you, like, let your clients take the lead, and a lot of that. Where I think if your client is actively talking about it or worried about it, they will feel really relieved to know that you get it, and to know that you’re thinking about that as well, and so kind of match that energy with them. Whereas other people who maybe are a little bit less concerned, yeah, I wouldn’t go into the big, deep conversation. Instead, I would just kind of very kind of unemotionally let them know, right? It’s just like a statement about I document, this is the word I use. Do you have any preferences? If you have any questions, you can let me know. And then if they’re just want to move on, then you just move on and you bring it up. But I do think this is, I also, it brings up for me that I have feelings about this. A lot of other therapists have feelings about this. And I try to be mindful, because I, I know that regardless of your political views, for example, you’re going to have to document about abortion if you work with with young women, right? And so regardless of what you feel about abortion, you might have to talk to a client about it, and you might have to document it. And when you go to document it, it might give you pause, regardless of what your personal feelings are about it. And so I do think it’s important that we evaluate what are our own feelings and discomfort and manage that and regulate it as much as we can. Right? So don’t like watch the news for an hour before you do a bunch of client sessions. Because, unless you’re looking at Taylor Swift being engaged, because that’s like the only happy news right now. But you know what I mean? Like, be mindful of what you’re bringing to the session, because I do think that there’s a heavy, there’s a heavy feeling around a lot of this, and it’s very easy to bring that to your clients, and that is not what we want to do. We want to bring it in an unemotional way and kind of match what their energy is with it. And so if they are really concerned, we want to show them we value that concern and that we would like to take their opinion into consideration. And if they’re not really concerned, and we don’t have reason to be, then like, or if we are concerned, we don’t need to put that on our client, right? Yeah, I think that’s a really good point.

Katie Vernoy 25:47
I think the other part of this, that is something that kind of goes along with this, is the times when we hedge or that we don’t necessarily put all the things in there. The thing that came up for me is the threat of an autistic registry, or potentially even folks with gender dysphoria, identity dysphoria, those types of things where an actual diagnosis might be the danger. And for me, that gets into accuracy, talking to your client about it. I mean, there’s, there’s a lot there. So do you have ideas on what to do about those things?

Dr. Maelisa McCaffrey 26:27
Yeah, in that, I would say, give yourself a lot of grace. Like you can only do the best you can with the information you have available at the time. And none of us knew that some of this stuff was going to happen six months ago or six years ago. And so you can never know potentially like that is a great example like potentially an Autism registry, and having a diagnosis of that, and for other people, having that actual diagnosis is extremely valuable, because that gets them services they need.

Katie Vernoy 27:03
Sure.

Dr. Maelisa McCaffrey 27:03
And without it, they’re not getting access to, like desperately needed services. And so a lot of these things are not always all good or all bad. And with documentation, I see that all the time. I’ve seen examples of people who use the I’m going to write as little bit little as possible strategy, and they’re not billing to insurance, and so they don’t worry about medical necessity, and they don’t want to use a diagnosis, and they really don’t like the word impairment, so they don’t emphasize that in their notes. And then their client has something significant happen, and applies for disability, and their client was denied. And thankfully, in that circumstance, because this is a real circumstance that happened. Thankfully that person also had a psychiatrist. And guess what? The psychiatrist don’t worry about that. So a psychiatrist notes were great and helps this person get a service they needed. But for that clinician that I was working with, it was very eye opening to see, you know, actually documenting in a way I don’t necessarily ascribe to or feel comfortable with, but documenting accurately could have helped my client, and I almost did my client a real disservice. And thankfully, somebody else did, you know, document in a different way. And on the flip side, yeah, there’s, there are circumstances where your clients can have negative things happen because of accurate things you write, and it’s really not our role to make that determination. It just isn’t. Because, like I talked about with court cases. I mean, if you have a good attorney, or they have a good attorney, they’ll make it work either way. It’s it’s not so much about what you write. And so I do want therapists to take some of that pressure off of themselves. Yes, we want to consider it ethically. Yes, I that’s why I really go back to always emphasizing informed consent, because it’s about, it’s not about trying to predict the future. It’s about letting your client know this is always a risk, and when clients have things documented about them, regardless of whether or not in the moment you think it’s good or bad, that is always a risk.

Curt Widhalm 29:05
I never would have thought that a podcast about documentation would turn into a ethical versus moral debate. And I think that that’s really what’s underlying this, is trying to wrestle with really, what are your morals? And you know, by the very nature of being licensed, you’ve agreed with the jurisdiction that you’re in to follow certain protocols. I think to credit you for already giving kind of some suggestions as far as different ways to maybe phrase things in some of the documentation that might weave that golden line of helping clients, line things. Are there other parts of the client file that we need to consider, whether it be what’s written in our informed consent, our documentation of intake questionnaires? Are there other places that we should really be thinking about, things that we haven’t discussed yet?

Dr. Maelisa McCaffrey 30:01
Yes, I will. So we’ve all heard the phrase. If it’s not written down, it didn’t happen. And I think, like way back in the day, I probably even said that myself. I really like a much better phrase, and I will quote Eric Strom. I don’t know if you’ve ever had him on the podcast, but he’s both an attorney and a licensed counselor, and what he says instead is, if it’s in the record, think about why. And so it’s always okay to question things. Like, do I need a copy of my client’s ID? A lot of the things we do, we do because they were always done, wherever we were before, or because somebody else did them. But is that a rule? I’ll tell you that’s not a law. At least it could be a law in some states. It’s not a law in states I’m aware of. It often is a requirement related to insurance if you take insurance, right? And so it’s not that things are always good or bad or even have to be done. And so questioning things like, when you’re like, oh my gosh, some people are having this existential like, this huge crisis about whether or not I have a client’s ID, and it’s like, Well, do you even need it, right? Like, is it, is it a requirement? And never, I would even say this about my advice, anything you hear on this podcourse or any other podcourse, your question is always, what’s your source? So if somebody tells you, Well, you have to do that, then say, what’s your source, right? Because a lot of people, their only source is some random supervisor or some experience they had, or even, I can tell you as a former QA person at a few different agencies, their QA person at an agency. That person is just telling you whatever is that agency’s policy, and they might tell you it’s because Medicare said this, but often that’s not accurate. So never trust just a person or hearsay. Always go back to, like, what’s your source? And think about that for yourself. So if you’re looking through your records and you’re like, I don’t like that, I have to do this, well then look at, why is it in your record? Like, do you actually have to have it? And it does take a little bit of digging, but I think if that, if it’s don’t do that with everything, right? Because that would be crazy making, and you’ll never finish looking at your documentation ever. So do that with the things that are really causing you anxiety, right? The things you’re absolutely concerned about, then, yes, those are the things you prioritize taking some time to look at. Is this an actual rule or law that I need to follow? And remember that even with that, we can all have like reasonable clinicians can disagree on these issues and have different policies and practices, and that’s okay, and you can have a different policy and practice around documentation than another clinician that you respect.

Katie Vernoy 32:54
There’s always concerns that I have around kind of what Curt was talking about, the legal, ethical versus moral arguments. And when we’re talking about whether it’s the Autism registry or folks that are seeking asylum or folks that may actively be targeted by the current administration, and depending on how medical records are treated in the future, there could be ways in which they these records are used against them or used to identify them. You know whether it’s a diagnosis or even just key phrases. And so I know you talked about the phrase for abortion being pregnancy loss. You have other types of advice for some of the hot button issues that people are facing right now, as far as, how do we accurately document but don’t put a target on our client’s back?

Dr. Maelisa McCaffrey 33:54
Yeah, I think the one that is so for abortion, it’s often pregnancy loss; for transgender, I often, especially if you’re working with teens, I talk about, just talk about identity issues, right, questioning identity, because that’s very common for for all of us, I guess. But yes, but more so for adolescents, right? And, you know, or even just discussing sexual, sexuality, right? That’s, I don’t think anyone thinks it’s unusual that a clinician is talking to an adolescent client about sexuality in general. And for immigration, that one, I do struggle with a little bit more, and so I’ll be honest that one’s a little bit more of a stretch, but my recommendations are really to focus on, like the related issues, so things such as transitions, things such as housing insecurity as a phrase that you might be able to use, things such as housing instability or just instability in their life in general. Right? Because these are a lot of the experiences of people right now, things such as family conflict, things such as cultural identity.

Katie Vernoy 35:10
I’ve also used safety. The client is worried about their family members safety.

Dr. Maelisa McCaffrey 35:15
Yeah, absolutely, absolutely, yeah. I think that’s especially helpful, and that’s where it can get a little bit more tricky, like, if your client is the one who you’re worried about with their immigration status, and like, you also don’t want to make them look paranoid, right when, when they might have some legit concerns, because there are raids going on in their very neighborhood, you know? And so just being mindful of that and and honestly, like, you don’t have to document everything. You just, you just don’t, and not everything is relevant. And so when in doubt, I would go back to that phrase of, if it’s in the record, think about why, like, why am I writing this down? Is it because I think it was extremely important, and if I don’t write this down, like you would never understand anything about this client or about what happened in the session. Is it because I accept insurance and I have to write certain things down for insurance, right? These are all acceptable answers, and those answers will vary, not only per clinician, but per client. So just thinking about like, if I have to write this down, or if I want to write this down, why?

Curt Widhalm 36:24
Thank you so much for spending some time with us and sharing your expertise with everybody. Where can people find out more about you and all of the wonderful information that you continue to put out there?

Dr. Maelisa McCaffrey 36:35
Yeah, thank you. I would say the best, so my my website is qaprep.com, that’s the best place to go. And I have a book which is super exciting, and it I am going to toot my horn and say it’s amazing. And I’ve gotten tons of great feedback on the book. Highly recommend buying the book. So if you go to if you the book is called Stress Free Documentation for Mental Health Therapists and it includes access to templates and lots of phrases that you can use and steal as cheat sheets for all the things, whether you work with insurance, whether you don’t work with insurance, but it’s essentially like you get a book on documentation, a training on documentation and a paperwork packet all in one. So if you go to qaprep.com/book, that’s where you’ll find out, where you can get that.

Curt Widhalm 37:25
And you can also go to our show notes at mtsgpodcast.com, and we will include links to Maelisa’s stuff over there as well. Follow us on our social media, join our Facebook group, the Modern Therapist’s Group, to continue on with this and other conversations, and until next time, I’m Curt Widhalm with Katie Vernoy and Dr. Maelisa McCaffrey.

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