record keeping and note taking for school counsellors lorna martin (204) 945-7964...
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RECORD KEEPING and RECORD KEEPING and NOTE TAKING NOTE TAKING for for SCHOOL COUNSELLORSSCHOOL COUNSELLORS
Lorna MartinLorna Martin
(204) 945-7964(204) 945-7964
[email protected]@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 [email protected](204) 945-7964or 1 800 282-8069, ext. 7964