Record Keeping

Record Keeping

1. Reasons for

   • Ethical expectation
   • Continuity/ aide memoire
   • Observe change over time
   • For other agencies
   • Organise own thoughts

2. Reasons against

   • Security problems
     • Use coding
     • Use a safe
   • Trust issues
     • In contract
   • Time consuming
   • Clients right to view
     • factual only
   • court access
     • avoids personal appearance

3. Case Notes

   • Access
     • Courts
       • Can Subpoena
       • Can demand a report
       • Can demand a personal appearance
     • Employer
       • Negotiate between client and Agency
     • Client
       • Automatic right to view
     • Accidental
       • Appropriate Security
         • Digital
           • Register under Data Protection Act
         • Safe
         • Filing Cabinet
     • Police
       • Search Warrant signed by a circuit judge
   • Format
     • Respectful, specific, factual
       • Issues
       • Interventions
         • Reasoning
       • Homework
       • Next session
       • Session length
       • Referring on
         • Child protection; terrorism; self harm
           • Written consent or via supervision
         • Material for supervision
           • Written consent
             • In Contract
         • More experienced/specialised colleague
           • Written Consent every time
       • Correspndence
     • Ink, dated and signed
       • Contracts

4. Process Notes

   • Access
     • Automatic client right
     • Destroy after every session
   • Aide memoire
     • Destroy after every session
   • Format
     • Temporary
       • Respectful, specific, some opinion
         • Diagnoses, hunches
         • Effect of client on counsellor

5. Destroy after counselling ends