Record Keeping

Record Keeping

Reasons for
1. Ethical expectation
2. Continuity/ aide memoire
3. Observe change over time
4. For other agencies
5. Organise own thoughts
Reasons against
1. Security problems
  1. Use coding
  2. Use a safe
2. Trust issues
  1. In contract
3. Time consuming
4. Clients right to view
  1. factual only
5. court access
  1. avoids personal appearance
Case Notes
1. Access
  1. Courts
    1. Can Subpoena
    2. Can demand a report
    3. Can demand a personal appearance
  2. Employer
    1. Negotiate between client and Agency
  3. Client
    1. Automatic right to view
  4. Accidental
    1. Appropriate Security
      1. Digital
        Register under Data Protection Act
      2. Safe
      3. Filing Cabinet
  5. Police
    1. Search Warrant signed by a circuit judge
2. Format
  1. Respectful, specific, factual
    1. Issues
    2. Interventions
      1. Reasoning
    3. Homework
    4. Next session
    5. Session length
    6. Referring on
      1. Child protection; terrorism; self harm
        Written consent or via supervision
      2. Material for supervision
        Written consent
        In Contract
      3. More experienced/specialised colleague
        Written Consent every time
    7. Correspndence
  2. Ink, dated and signed
    1. Contracts
Process Notes
1. Access
  1. Automatic client right
  2. Destroy after every session
2. Aide memoire
  1. Destroy after every session
3. Format
  1. Temporary
    1. Respectful, specific, some opinion
      1. Diagnoses, hunches
      2. Effect of client on counsellor
Destroy after counselling ends

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	Created by Patrick Keep about 6 years ago