Text of RECORD KEEPING and NOTE TAKING for SCHOOL COUNSELLORS Lorna Martin (204) 945-7964...
RECORD KEEPING and NOTE TAKING for SCHOOL COUNSELLORS Lorna Martin (204) 945-7964 email@example.com
KEY QUESTIONS What do I record? How much do I record? Where do I record? How long do I keep information? What information can I share? To whom can I share information? How do I decide what is confidential and what is shareable?
THE BIG PICTURE Cumulative file Pupil Support file Youth Criminal Justice file IEP BIP ITP Resource Reports Clinician Reports Counselling Reports Counsellors Case notes Clinicians Case notes Counsellors Caseload Record Teachers Mark book Teachers Daily Record
CASE NOTES style and format Write your notes with the expectation that others will read them with a critical eye. Dont alter the record after the fact. Strike out the comment and replace it with correction. Be as specific and precise as possible. Focus on objective, observable behaviours and statements. Avoid jargon or diagnostic labels.
Include Clients name Date Referral information (from, to) Interagency contacts and results Other contacts and results Signature of counsellor CASE NOTES background
Presenting problem or concern Main points or main issues discussed Relevant information on interventions Long-term/short-term goals Indications of progress Plans/homework Actions taken Appendices (e.g., drawings, letters, tests) THE RECORD SHOULD SHOW THAT REASONABLE, ETHICAL STEPS HAVE BEEN TAKEN CASE NOTES content
SAMPLE CONFIDENTIAL COUNSELLING REFERRAL Date: __________________________ Student Name: ___________________________________ STATUS: CRITICAL Urgent as soon as possible Is the student aware of this referral? yes no Referral by: self peer name___________________________ teacher name___________________________ administrator name___________________________ parentname___________________________ other name___________________________ AREA OF CONCERN: Academic school achievement school leaving attendance course change/timetable study skills subject area concern test taking preparation scholarships post-secondary requirements Behaviour classroom returning from suspension social skills mediation Career making a career/educational choice CHOICES/Bridges/Career Cruising/inventory session resume writing portfolio Personal stress friendship social/emotional finances/money health conflict resolution self-esteem home relations peer pressure gang mental health weight sexuality housing Abuse harassment bullying physical emotional sexual verbal drug/alcohol/substance self Other: ______________________________________________________________ Additional information:________________________________________________ Notes: see reverse side ________________________________________________________________________________________________________________________________
GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING PERSONAL information CAN be shared under the following circumstances: With written consent OR To avert or minimize imminent danger to the health or safety of any person OR To report a child who might need protection under the Child Welfare Act OR Where organizations that are subject to FIPPA are involved in a common program or integrated service OR GREEN LIGHT
GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING (contd) PERSONAL information CAN be shared under the following circumstances: By Order of the Court OR As under the Youth Criminal Justice Act (Canada) to facilitate the rehabilitation of a young person OR To cooperate with a police and/or child welfare investigation GREEN LIGHT
GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING (contd) Generally HEALTH information CAN be shared if the situation meets at least ONE of the following: With written consent OR To avert or minimize imminent danger to the health or safety of any person OR To report a child who might need protection under the Child Welfare Act OR By Order of the Court OR To a person who is responsible for providing continuing treatment and care to the individual (need not be a formal health services provider) GREEN LIGHT
GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING (contd) In the following circumstances obtain more information and/or get advice from a supervisor, consultant or lawyer: Consent is not provided or refused but there may be a health or safety issue for any individual or groups To report criminal activity to police (pursuant to FIPPA) Where there is a demand or request to produce information for a legal proceeding When a professional code of ethics may limit disclosure YELLOW LIGHT
GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING (contd) Information can NEVER be shared if there is: A legislative requirement barring disclosure No consent and no need to know nor overriding health/safety concerns Consent but no need to know nor overriding health/safety concerns RED LIGHT
LEGISLATION The Public Schools Act (PSA) The Education Administration Act (EAA) The Freedom of Information and Protection of Privacy Act (FIPPA) The Personal Health Information Act (PHIA) The Youth Criminal Justice Act (CJA)
The Acts cover a range of issues relating to such matters as... The pupil file Access to pupil files Refusal of access to pupil files Types of information that may or must be kept
The Guidelines on the Retention and Disposition of School Division/ District Records School boards must have a written policy concerning: retention and destruction of records security provisions decision making re: access requests
The Guidelines on the Retention and Disposition of School Division/ District Records (contd) School boards must have a written policy concerning: process and procedures for culling of files procedures for confidential destruction of information file transfer
Every school division/district to appoint an Access and Privacy officer.
PUPIL FILES Definition: A record or collection of records respecting a pupils attendance, academic achievement and other related matters in the possession or control of a school board. (PSA 42.2)
WHAT SCHOOLS DO The school is authorized to collect information that relates directly to what schools do. Schools provide educational programs and services supporting the pupils educational progress.
INFORMATION COLLECTION Collect only as much information as is needed for the purpose for which it is collected When collecting directly from the individual, the person must be informed of the purpose and authority for the collection and the name of a contact person.
PUPIL FILES May be organized and separated into sub-files by component Three components: cumulative file component pupil support file component youth justice file component
CUMULATIVE FILE COMPONENT Standard or routine information that schools have on all pupils Behavioural misconduct information including suspensions/expulsions Child custody, guardianship agreements or orders Home/school communications
CUMULATIVE FILE COMPONENT (contd) Cross-reference listing identifying the location of all information about a pupil that is held by the school division/district Results of tests administered to most students Individualized Education Plan and/or Health Care Plan, and/or Behavioural Intervention Plan and/or Individualized Transition Plan
CUMULATIVE FILE COMPONENT (contd) Up-to-date notations or referrals to/contacts with external agencies Admission advisement concerning whether the student has used or is continuing to use social service psychological/psychiatric or counselling resources
PUPIL SUPPORT FILE COMPONENT Exists for some students Information about a student may be held in more than one location if a system of cross- referencing in place Detailed documentation about the provision of resource services from within or outside of the school division/district
PUPIL SUPPORT FILE COMPONENT (contd) Ongoing health/psycho-social / counselling information School clinician reports / correspondence / logs / notes Results of specialized diagnostic tests Service provider reports
SCHOOL COUNSELLING CASE FILES COMPONENT Exists for some students Often cross-references with clinical reports Ongoing counselling information (file not required for one-time only counselling events) Indicates referrals and consultations Includes sufficient information to allow monitoring and evaluation of services and timelines by counsellor Includes relevant details to support students needs
CASELOAD RECORDS Considered equivalent to a teachers daily record Indicates daily activities (e.g., classroom guidance sessions, career cruising, mediation for single event, suspension transitioning) Shows planned events/sessions for upcoming day/week/month Does NOT contain confidential information; may contain names of counsellees that ought to be shared only on a need to know basis