Selective documentation, is it appropriate or ethical in education or medicine?

Has documentation become more about the person documenting than the person whom we are documenting about? As we were once again in the position to need to advocate for our oldest child, who has autism, this week. At some point I looked at all the documentation lying before me with great disgust. Lying before me lay documentation that completely backed up what the educational institution said happened, but having been present at the meetings that were documented I couldn't help but notice those documents in no way reflected what truly happened. My husband, Son and I all clearly remember our son being asked to sign the documentation as it was written because the program my son wanted wasn't in the computer yet. Of course, we were assured it would be corrected when the program became available in the computer. So it's just a thought, but wouldn't it have been more ethical and honest to have written that on the documentation instead of leaving it completely out? I also found it interesting that the program was indeed changed to the one he wanted to be in, but they had no documentation showing when or why that happened.

So here's my question: Are we all now so afraid of the "powers that be" that we are doing those we serve a major disservice by not documenting all sides of the story? Are we documenting just to avoid liability when we should be documenting the needs of the individual?

I absolutely agree that we all have a certain amount of minimum documentation that must be done and I also agree that we should document in such a way that your organization is not placed in a situation where they become liable. If we are now omitting information just to prevent our oranizations from being liable how can we possibly be meeting all the needs of those individuals that need our help. We must document their needs before we can address those or their needs just fall through the cracks.

In our case, the documentation could have just as easily stated that the program he had selected was not available in the computer, but it would be switched when that option came available. Instead it was stated in such a way that it appears he never asked about the only program in which he was interested. While we will regroup and get past this hurdle, I ask those of you who are working in education or health care and are responsible for documenting the needs of others to ask yourself, are you serving the individual with a need or are you only just protecting yourself and your organization? I know I, for one, will endevour to make sure the needs of those I serve are failrly represented as well as the needs of the organizations who employ me.