Risk Management: Psychologists Producing Quality, Well-Documented Patient Care

By Samuel Knapp, Ed.D.
January 26, 2018

risk management well documented patient careThe goal of risk management is to reduce the likelihood of discipline by a malpractice court, licensing board, ethics committee or another oversight body. Risk management is an important topic, but it could be viewed as a subset of the larger issue of how to deliver high quality professional services.

The best risk management strategy is to provide and document good patient care. The likelihood of being the subject of a complaint correlates positively with the quality of services delivered, although other random factors are sometimes involved.

I know this approach annoys many psychologists who would prefer to have risk management reduced to handing out a few forms at the start of treatment or some similar task that is easy to perform. Alas, that is not the position I take. Good risk management is embedded in the quality of every professional service performed.

Being competent is the most important risk management strategy. Epstein and Hundert (2002) defined competence as: “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individuals and communities being served.” According to this useful definition, the “how” of competence is both on-going (“habitual”) and case specific (“judicious”).


Effective psychologists develop habits of practice that include creating and maintaining good relationships with patients, accepting feedback constructively, adopting an attitude of humility and being willing to work hard at one’s craft.

The ingredients of a good relationship have been described elsewhere in detail and I will not summarize that research, but the most overlooked element is just being polite.

During early 1990s, I was the staff person assigned to the ethics committee of my state psychological association as it processed ethics complaints. I noticed many complaints referenced rude behavior on the part of the psychotherapist. Although rudeness itself is not an ethics violation, it often offends patients enough for them to want to file a complaint.

Effective psychotherapists are vigilant about patient progress. Some may gather systematic feedback in the form of outcome measures. Others receive feedback simply by regularly asking patients a series of questions that tap the extent to which they believe that their goals are being met.

The failure of patients to respond quickly to psychotherapy is a cause of concern, because those who fail to respond early to treatment are statistically more likely to fail at treatment. It is true that some patients get worse before they get better. However, it is preferable that patients get better before they get even better. Effective psychotherapists will identify and address the lack of early progress.

Many psychologists feel offended when I suggest the importance of a systematic process for evaluating patient progress. They tell me that any competent psychologist can tell whether  patients are improving or not. My response is that, for the most part, they are correct, but I estimate that on the average they are wrong about 4 percent of the time, 1 of every 25 patients.

Walfish et al. (2012) found that psychotherapists estimated that 3.6 percent of patients deteriorated during treatment, yet Castonguay et al. (2010) found that about 8 percent of patients deteriorated. That means that, on average, 4 percent of patients will deteriorate even though their psychotherapists do not detect the deterioration.

Finally, effective psychotherapists are appropriately humble about their abilities and accept feedback constructively. They can reflect productively on their skills and ways to improve their services. These psychologists know that they cannot reach their fullest professional potential unless they take active steps to increase the resources available to them.

This means that they deliberately surround themselves with a set of resources, contacts, peers and friends (In 2012, Brad Johnson and colleagues referred to this as a competent community) that can promote the quality of their service (and they can help promote the quality of the services provided by their peers.)

Ideally that competent community would include resources on legal and ethical issues. Some SPTAs provide consultation to their members and some professional liability insurers, such as The Trust, do so as well.


The second part of competence is using good judgment. Effective psychologists have enough clinical skill and ethical sensitivity to know when a situation requires careful decision making. They are sufficiently aware of their emotional well-being that they can detect when their emotions risk interfering with calm deliberations. They have a competent community to rely upon when they need consultation.

Finally, competent psychologists document important decisions carefully. Unfortunately, I still encounter some who argue that psychologists should never keep any notes in a crisis, such as when a patient has serious suicidal thoughts. They claim that an attorney can take the notes and twist them around to mean anything.

This is not true. If the notes stated that the patient was asked about suicide and denied any suicidal thoughts, then the assumption is that the patient was asked about suicide and denied it. No crafty attorney can undo that statement.

Problems occur, however, if the notes are gibberish. Competent psychologists write notes in high-risk situations that would give any third party a general idea of the issues being faced and the decision making used by the psychologist.

References available from author.

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Samuel Knapp, Ed.D., ABPP, has been director of professional affairs for the Pennsylvania Psychological Association since 1987 and writes frequently on the topic of professional ethics. His email is Sam@papsy.org.

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