RECORD KEEPING and RECORD KEEPING and NOTE TAKING NOTE TAKING for for SCHOOL COUNSELLORSSCHOOL COUNSELLORS

Lorna MartinLorna Martin

(204) 945-7964(204) 945-7964

lormartin@gov.mb.calormartin@gov.mb.ca

KEY QUESTIONSKEY 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 PICTURETHE BIG PICTURE

Cumulative file

Pupil Support file

Youth Criminal Justice file

IEP

BIP

ITP

Resource Reports

Clinician Reports

Counselling Reports

Counsellor’s Case notes

Clinician’sCase notes

Counsellor’s CaseloadRecord Teacher’s

Mark book

Teacher’s Daily Record

CASE NOTES – style and formatCASE NOTES – style and format

Write your notes with the expectation that others will read them with a critical eye.

Don’t 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 Client’s name Date Referral information (from, to) Interagency contacts and results Other contacts and results Signature of counsellor

CASE NOTES – backgroundCASE 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 – contentCASE NOTES – content

SAMPLESAMPLECONFIDENTIAL COUNSELLING REFERRALDate: __________________________Student Name: ___________________________________STATUS: CRITICAL Urgent as soon as possibleIs the student aware of this referral? yes noReferral by: self peer name___________________________ teacher name___________________________ administrator name___________________________ parent name___________________________ 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 GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARINGPROFESSIONAL INFORMATION SHARING

PERSONAL information CAN be shared under the following circumstances:

With written consentOR

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 ActOR

Where organizations that are subject to FIPPA are involved in a common program or integrated service

OR

GREENLIGHT

GENERAL GUIDELINES FOR GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING PROFESSIONAL INFORMATION SHARING

(cont’d)(cont’d)

PERSONAL information CAN be shared under the following circumstances:

By Order of the CourtOR

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

GREENLIGHT

GENERAL GUIDELINES FOR GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING PROFESSIONAL INFORMATION SHARING

(cont’d)(cont’d)

Generally HEALTH information CAN be shared if the situation meets at least ONE of the following:

With written consentOR

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 ActOR

By Order of the CourtOR

To a person who is responsible for providing continuing treatment and care to the individual (need not be a formal health services provider)

GREENLIGHT

GENERAL GUIDELINES FOR GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING PROFESSIONAL INFORMATION SHARING

(cont’d)(cont’d)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 GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING PROFESSIONAL INFORMATION SHARING

(cont’d)(cont’d)

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

LEGISLATIONLEGISLATION 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 The Acts cover a range of issues relating to such issues relating to such

matters as...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 The “Guidelines on the Retention and Disposition of School and Disposition of School Division/ District Records”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 The “Guidelines on the Retention and Disposition of School and Disposition of School Division/ District Records” Division/ District Records” (cont’d)(cont’d)

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 FILESPUPIL FILESDefinition:

A record or collection of records respecting a pupil’s

attendance, academic achievement and other related matters in the

possession or control of a school board.

(PSA 42.2)

WHAT SCHOOLS DOWHAT SCHOOLS DO

The school is authorized to collect information that relates directly to what schools do.

Schools provide educational programs and services supporting the pupil’s educational progress.

INFORMATION COLLECTIONINFORMATION 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 FILESPUPIL FILES

May be organized and separated into sub-files by component

Three components:cumulative file componentpupil support file componentyouth justice file component

CUMULATIVE FILE COMPONENTCUMULATIVE 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 CUMULATIVE FILE COMPONENT (cont’d)(cont’d)

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 CUMULATIVE FILE COMPONENT (cont’d)(cont’d)

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 PUPIL SUPPORT FILE COMPONENTCOMPONENT

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 PUPIL SUPPORT FILE COMPONENT (cont’d)COMPONENT (cont’d)

Ongoing health/psycho-social / counselling information

School clinician reports / correspondence / logs / notes

Results of specialized diagnostic tests

Service provider reports

SCHOOL COUNSELLING SCHOOL COUNSELLING CASE FILES COMPONENTCASE 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 student’s needs

CASELOAD RECORDSCASELOAD RECORDS

Considered equivalent to a teacher’s 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

CHILD PROTECTION/CHILD PROTECTION/SUSPICION OF ABUSE REPORTSSUSPICION OF ABUSE REPORTS

Are NOT retained At the school In the support file In the school counselling case files In the caseload recordsbecause the report is based on an event

or suspicion that may be unfoundedThe report is stored securely and

confidentially with the school division office as per division policy.

The information The information comprising the pupil comprising the pupil support file and the support file and the school counselling school counselling

case files should be case files should be securesecure

All recorded information about a pupil that is either generated or received by school

division/district staff is in the custody, or under

the control of the school division/district

ACCESS AND PRIVACYACCESS AND PRIVACY Parent, guardian, or pupil Staff access:

To the extent that the information is necessary to assist in the educational progress or schooling of the pupil

REFUSAL TO ACCESSREFUSAL TO ACCESSA school board may refuse to provide access

to all or part of a pupil file where disclosure could reasonably be expected to:

cause unreasonable invasion of privacy of a third party;

be detrimental to the education of the pupil;

cause serious physical or emotional harm to the pupil or another person; or

be injurious to the enforcement of an enactment or the conduct of an investigation under an enactment

(PSA 42.3(2))

Application must Application must be made for be made for

access to recordsaccess to records

Access may be Access may be denied under denied under

certain conditionscertain conditions

ACCESS AND PRIVACYACCESS AND PRIVACY

Under the PSA, an employee competent to interpret the information in the file must be made available to assist any parent or pupil who has been granted access to a pupil file

DISCUSSIONDISCUSSION Distinction between cumulative files, pupil

support files, criminal youth justice files, clinical files, counselling files, caseload records and resource teacher plans

Access to files – PSA legislation vs FIPPA legislation

Sharing confidential information – ‘need to know’ for personal programming and safety

Your context

FOR FURTHER INFORMATIONFOR FURTHER INFORMATION

Contact:Lorna Martinlormartin@gov.mb.ca(204) 945-7964or 1 800 282-8069, ext. 7964