RECORD KEEPING

IS IT DESIRABLE TO KEEP RECORDS?

!Although not a legal requirement, it is considered ethically prudent for counselors to keep records in relation to their clients. !

•  Why Keep Records?????!

•  ‘If it is not documented it never happened!’!

•  Moline, Williams and Austin (1998) list a number of arguments for keeping records…

•  Record keeping has become a ‘standard of care’ practice set by most professional organisations

•  Adequate records often serve as a counselor’s defence against malpractice claims or in the event of being charged with an ethical violation.

•  !

•  A record can serve clients by reflecting their condition at a particular time

•  records document that treatment occurred

•  Records can be useful for clients in the event of transferring to a new therapist.

!‘Practitioners are advised to keep appropriate

records of their work with clients unless there are good and sufficient reasons for not keeping any

records at all’. (BACP, Guidelines for good Practice).

!

a) The process or writing records involves the counselor in organising her own thoughts and feelings.

b)  Records provide counselors with an aide-memoire for incidental details such as the names of people

c) Systematic record-keeping makes any changes in the client’s material over a series of sessions more apparent.

d)  Systematic record-keeping provides evidence of the degree of care taken by the counselor in her work.!

•  “Professional ethics require that clients have consented to records being kept. Ethically, this forms part of the client’s full and informed consent. (Tim Bond, 2010 pg 198).

How long do we keep records?

•  The Law Society recommends the keeping of records for six years from the date of the last contact, which corresponds with the time limits for some legal actions.

•  Client records remain confidential even after one’s death or the death of one’s clients and that confidentiality needs to be protected.

Security of Records!•  IACP Code of Ethics 1.2.8. states the

counselor must store, handle, transfer and dispose of all records (including written, electronic, audio and video) securely and in a way that safeguards the client’s right to privacy’ !

•  Records be securely locked away and accessed only by the counselor

•  A split system of record keeping is most acceptable so session records and client identification details are not filed together.

•  For counselors working in agencies, policies regarding access differ and counselors would need to familiarise themselves with agency policies and procedures.

•  Computer records can be protected by passwords with the principles being similar to those of paper records.

•  It is important to remember that the Data Protection Act 1998 and 2003 now covers all recorded information in whatever format, not just that held on computers.

•  Clients have a right to know what information is held on them and to have freedom of access to it.

•  Data Protection Act…. 2003 •  Any member of the public has a right to data

protection when your details are : •  held on a computer •  held on paper or other manual form as part of

a filing system •  made up of photographs or video recordings

of your image or recording

Who has access to records?!

•  Clients may have access to their own records to ensure accuracy or permit challenge, the exception being where a doctor of psychologist may deem access to be detrimental to the client’s mental or physical wellbeing.

•  “Clients are only entitled to access to records which refer to them as identifiable persons because they are named, or their identity can be inferred from the information recorded.

•  (Tim Bond, 2010, pg 203)

•  In Agencies employing counselors access to client records may not be restricted to the counselor. e.g. manager or other professional staff

•  In supervision if the counselor brings details from their client records, client should remain unidentifiable.

•  Gardai have no right to access to confidential information except in circumstances such as …….

•  where a client has given consent •  compliance with a court order •  where public interest outweighs client

confidentiality

•  The use of counselors’ records in court

•  How to respond to a solicitors request for a report on your client…..???????

•  Make sure you receive the solicitor’s request for a report in writing.

•  Make sure that if the solr is requesting a medical report that you inform the solicitor that you are not a medical practitioner and therefore cannot comply with his request.

Matters to include in Client Records?

•  There are no fixed rules about what ought to be included in counseling records or how they ought to be writen. The guiding principle is that the type of record should be one that supports the therapy ane enables it to be delivered to a reasonable standard of care”. T. Bond (2010)!

• Write brief case-notes as soon as possible after seeing a client !

• focus primarily on how you were working with the client, the interventions used, the process which you observed between you in the therapeutic relationship !

• any tasks which the client agreed to work on.!!

•  What is included should be written with the possibility of the client seeing the record at a later date and the possibility that the records may be required for use in legal dispute. T. Bond (2010, pg 208)

•  Each counselor has to develop a style that is sufficient to support the counseling but without being excessive in what is recorded. (T. Bond (2010, pg 208)

What to include in Records?

•  Document missed sessions •  Use clear behavioural language •  Avoid subjective depricating remarks •  Keep notes brief and concise as possible •  Include interventions, treatment strategies

and any follow-up measures taken •  Copies of any correspondence from the

client or relating to work with the client

•  Case notes should never be altered or tampered with after they have been entered into the client’s record. !

•  Notes are not ‘privileged’ under the law and could be subpoenaed and required to make them available to the officers of the court. In some cases this could mean that they might be copied and quite widely distributed to the police, solicitors and other parties on both sides.!

•  Counsellors bear the ultimate responsibility for what they write, how they store and access their records, what they do with these records, and when and how they destroy them (Nagy, 2000). !

What is malpractice?!

•  Malpractice is a legal concept involving negligence that results in injury or loss to the client. Professional negligence can result from unjustified departure from usual practice or from failing to exercise due care in fulfilling one’s responsibilities.!

Summary • Record keeping has become a ‘standard of care’ practice set by most professionals. • Adequate records often serve as a counselor’s defence against malpractice claims or in the event of being charged with an ethical violation. • A clinical record can serve clients by reflecting their condition at a particular time. • Records document that treatment occurred.

• Records can be useful for clients in the event of transferring to a new counselor

• Records can help counselors improve their skills and provide more effective treatment for clients.