Spring 2026 Issue

Documentation Challenges: Documentation Paradox
By Elizabeth S. Goar
Social Work Today
Vol. 26 No. 2 P. 6

Patient Privacy vs Medical Necessity and Care Continuity

A growing slate of state-level patient privacy laws is forcing social workers to walk a tightrope between documenting sufficient detail to establish medical necessity and ensure continuity of care while maintaining sufficient ambiguity to protect their clients from the potential repercussions of those laws.

In one study, many of the social workers surveyed acknowledged that they do not record certain topics, or do so in very general terms, to protect client privacy or avoid legal exposure.1 It is a practice they justify as a means of preventing harm or managing sensitive information in today’s regulatory environment. Unfortunately, their efforts to navigate a complex compliance paradox can have very real consequences for care and reimbursement.

“Documenting clinical information is complex: what and how much to write, what to reveal, what not to reveal and why, and how to tie it all together so it presents a cohesive picture without divulging confidentiality. That’s quite a balance to strike,” says Beth Rontal, MSW, LICSW, founder of Document Wizard, where she helps social workers master documentation. “We need to document what happened in session, but we can’t tell the drama; we can’t tell the story.”

A Legal and Ethical Conundrum
Today’s social workers are asked to document care within a system that pulls them in opposing directions: information-sharing rules push for transparency and immediate client access; ethical and legal obligations require protecting highly sensitive details; and payers expect granular documentation to justify medical necessity. The result is a compliance paradox in which documenting too much can create legal or ethical risks, while documenting too little can lead to denials, audits, or care gaps.

Behind it all are a growing number of states regulating when, how, and with whom sensitive information related to sexual orientation/gender identity, reproductive health, and substance abuse disorder is captured and shared.

Some states are taking a protective approach, strengthening confidentiality, limiting responses to out-of-state subpoenas, and offering clear protections for documenting sensitive information such as reproductive health care. Others are restrictive, with laws that increase legal exposure and the risk that sensitive information will be subpoenaed or used in investigations, and that place greater pressure on clinicians to document in ways that can be used for enforcement. The result is a patchwork compliance landscape in which the same clinical note may be protected in one state but legally risky in another.

“They used to say dance like nobody’s watching. At this point, you need to write as if everyone is watching,” says Marcy Pullard, LCSW, owner of The Clinician’s Development Center and creator of The Essentials of Documentation, an online distance learning program focused on documentation skills for social workers. “The push-pull is that you want transparency … but you’re also concerned about saying too much because you don’t know who will see it. It’s a huge balancing act.”

She points to parental access to a minor child’s medical records—which vary from state to state—as potentially having a chilling effect on what a child may say in therapy out of fear that their parents will be angered by what they read. However, limiting what is documented can lead to unsafe situations for the child.

“It’s beyond a catch-22,” Pullard says.

Collateral Damage
Limited or vague documentation can result in incomplete or ineffective information, affecting continuity of care and care outcomes. This is particularly true whether social workers are part of a multidisciplinary team or are responsible for a single, siloed aspect of the patient’s care.

Pullard cites her work conducting psychiatric evaluations in an emergency department as one such situation. She does her assessment, makes the hospitalization determination, and moves on.

“This is where the continuity of care comes in, because my note starts everything in terms of psych,” she says. “I must be clear, because no one talks to me about my notes. My note is all they get.”

Pullard adds: “Social workers need to focus on compliance and meaning … They need to think about their clinical decisions and what they’re based on, particularly when there’s a risk—suicide, homicide, serious substance use, or other risk and safety concerns. There’s medical necessity … and continuity of care because the whole point of your notes is to say, ‘this is what happened, and this is what we’re working on.’ If I’m not here, someone needs to be able to pick this [case] up.”

Finding Balance
Unfortunately, there is no magic formula for striking the precise balance needed to appease both sides of the paradox. Much of it comes down to nuance, situation, and clinical judgement. There are times when some details of the story may be supportive of the client, Rontal explains. Consider discussing what to include with the client and use client-centered language (eg, “Client reports that …”), so the social worker isn’t making a declaration of fact but stating what the client reports.

In another example, after Texas successfully challenged federal law protecting information on abortion and reproductive health, social workers must proceed with extreme caution should a pregnant patient state they are considering an abortion. Documenting the encounter with specificity could put the patient in legal jeopardy, depending upon the state of practice.

“We don’t know who can get access to these records,” Rontal says. “So, do you say that the client is considering an abortion? No. Never use those words. Instead, note the client reported being concerned about making an important medical decision.”

This same language can be applied to medical issues related to gender-affirming care.

While health-related information is typically at the center of this documentation storm, there are other scenarios wherein documentation can create legal or ethical conflicts for social workers and clients. For example, if a partner confesses to an affair during therapy, because the client’s record can be subpoenaed during a divorce, that level of detail can be used against the client. It’s why discretion is critical.

“You get creative. ‘The client expressed ambivalence about their marriage.’” Rontal says.

Immigration enforcement is another sensitive documentation area that has become more prevalent nationwide, particularly among social workers who work in marginalized communities. Accurate but vague is the order of the day when documenting what an immigrant—whether undocumented or not—might share about their experiences or fears regarding enforcement actions. For example:

• Don’t write: “Client reported seeing her next-door neighbor arrested by ICE, and worried about what will happen to her children if she’s arrested.”

• Instead write: “Client reported being scared for her personal safety and how it could affect her children.” Or “Client reported safety concerns in her neighborhood (or community) and how that may impact her family.”

Rontal explains that “documentation needs to translate a nonlinear intuitive therapeutic process into a clear, linear narrative on paper and emphasizes that the balance between privacy and compliance comes from focusing on thoughts, feelings, and clinical themes rather than detailed storytelling.”

This approach aligns with the “Golden Thread,” a documentation framework that connects each phase of care—from assessment to discharge—showing how interventions relate to goals and medical necessity.
“When clinicians understand what the Golden Thread is and how it supports medical necessity, they can document a client’s progress clearly and compliantly without increasing risk exposure,” she says.

To Pullard, the challenge with documenting sensitive information is exacerbated by the mixed signal it sends to clients. People are encouraged to talk about issues with gender, sexuality, and substance abuse, as well as relationships, immigration status, and a host of other issues that can impact mental health and wellness. But not knowing who may see that information and why can suppress that openness.

“There’s a huge balancing act. You try to avoid stigmatizing language … and protect [the client’s] dignity, but at the same time you want it to be accurate. You must communicate so many things [without] telling the world” too much,” she says. This requires the ability “to elaborate without being extremely long-winded.”

— Elizabeth S. Goar is a freelance health care writer based in Wisconsin.

Reference
1. Schneider D. Ensuring privacy and confidentiality in social work through intentional omissions of information in client information systems: a qualitative study of available and non-available data. Digit Soc. 2022;1(3):26.