2. IS IT DESIRABLE TO KEEP
RECORDS?
!
Although not a legal requirement, it is
considered ethically prudent for counselors to
keep records in relation to their clients.
!
3. • Why Keep Records?????!
• ‘If it is not documented it never
happened!’!
4. • Moline, Williams and Austin (1998) list a
number of arguments for keeping records…
• Record keeping has become a ‘standard of
care’ practice set by most professional
organisations
• Adequate records often serve as a
counselor’s defence against malpractice
claims or in the event of being charged
with an ethical violation.
• !
5. • A record can serve clients by reflecting their
condition at a particular time
• records document that treatment occurred
• Records can be useful for clients in the event
of transferring to a new therapist.
6. !
‘Practitioners are advised to keep appropriate
records of their work with clients unless there are
good and sufficient reasons for not keeping any
records at all’. (BACP, Guidelines for good
Practice).
!
7. a) The process or writing records involves the
counselor in organising her own thoughts and
feelings.
b) Records provide counselors with an aide-
memoire for incidental details such as the
names of people
c) Systematic record-keeping makes any changes
in the client’s material over a series of
sessions more apparent.
d) Systematic record-keeping provides evidence
of the degree of care taken by the counselor in
her work.!
8. • “Professional ethics require that clients have
consented to records being kept. Ethically, this
forms part of the client’s full and informed
consent. (Tim Bond, 2010 pg 198).
9. How long do we keep records?
• The Law Society recommends the keeping
of records for six years from the date of the
last contact, which corresponds with the
time limits for some legal actions.
• Client records remain confidential even
after one’s death or the death of one’s
clients and that confidentiality needs to be
protected.
10. Security of Records!
• IACP Code of Ethics 1.2.8. states the
counselor must store, handle, transfer and
dispose of all records (including written,
electronic, audio and video) securely and in
a way that safeguards the client’s right to
privacy’
!
11. • Records be securely locked away and accessed
only by the counselor
• A split system of record keeping is most
acceptable so session records and client
identification details are not filed together.
• For counselors working in agencies, policies
regarding access differ and counselors would
need to familiarise themselves with agency
policies and procedures.
12. • Computer records can be protected by
passwords with the principles being similar to
those of paper records.
• It is important to remember that the Data
Protection Act 1998 and 2003 now covers all
recorded information in whatever format, not
just that held on computers.
• Clients have a right to know what information
is held on them and to have freedom of access
to it.
13. • Data Protection Act…. 2003
• Any member of the public has a right to data
protection when your details are :
• held on a computer
• held on paper or other manual form as part of
a filing system
• made up of photographs or video recordings
of your image or recording
14. Who has access to records?!
• Clients may have access to their own records to
ensure accuracy or permit challenge, the exception
being where a doctor of psychologist may deem
access to be detrimental to the client’s mental or
physical wellbeing.
15. • “Clients are only entitled to access to
records which refer to them as
identifiable
persons because they are named, or their
identity can be inferred from the
information recorded.
• (Tim Bond, 2010, pg 203)
• In Agencies employing counselors access
to client records may not be restricted to the
counselor. e.g. manager or other
professional staff
16. • In supervision if the counselor brings
details from their client records, client
should remain unidentifiable.
• Gardai have no right to access to
confidential information except in
circumstances such as …….
• where a client has given consent
• compliance with a court order
• where public interest outweighs client
confidentiality
17. • The use of counselors’ records in court
• How to respond to a solicitors request for a
report on your client…..???????
• Make sure you receive the solicitor’s
request for a report in writing.
• Make sure that if the solr is requesting a
medical report that you inform the solicitor
that you are not a medical practitioner and
therefore cannot comply with his request.
18. Matters to include in Client
Records?
• There are no fixed rules about what ought to
be included in counseling records or how
they ought to be writen. The guiding
principle is that the type of record should be
one that supports the therapy ane enables it
to be delivered to a reasonable standard of
care”. T. Bond (2010)!
19. • Write brief case-notes as soon as possible
after seeing a client !
• focus primarily on how you were working with
the client, the interventions used, the process
which you observed between you in the
therapeutic relationship !
• any tasks which the client agreed to work on.!
!
20. • What is included should be written with the
possibility of the client seeing the record at
a later date and the possibility that the
records may be required for use in legal
dispute. T. Bond (2010, pg 208)
• Each counselor has to develop a style that is
sufficient to support the counseling but
without being excessive in what is recorded.
(T. Bond (2010, pg 208)
21. What to include in Records?
• Document missed sessions
• Use clear behavioural language
• Avoid subjective depricating remarks
• Keep notes brief and concise as possible
• Include interventions, treatment strategies
and any follow-up measures taken
• Copies of any correspondence from the
client or relating to work with the client
22. • Case notes should never be altered or
tampered with after they have been entered
into the client’s record. !
• Notes are not ‘privileged’ under the law and
could be subpoenaed and required to make
them available to the officers of the court. In
some cases this could mean that they might
be copied and quite widely distributed to the
police, solicitors and other parties on both
sides.!
23. • Counsellors bear the ultimate
responsibility for what they write, how
they store and access their records,
what they do with these records, and
when and how they destroy them
(Nagy, 2000). !
24. What is malpractice?!
• Malpractice is a legal concept involving
negligence that results in injury or loss
to the client. Professional negligence
can result from unjustified departure
from usual practice or from failing to
exercise due care in fulfilling one’s
responsibilities.!
25. Summary
• Record keeping has become a ‘standard of care’
practice set by most professionals.
• Adequate records often serve as a counselor’s
defence against malpractice claims or in the
event of being charged with an ethical violation.
• A clinical record can serve clients by reflecting
their condition at a particular time.
• Records document that treatment occurred.
26. • Records can be useful for clients in the event of
transferring to a new counselor
• Records can help counselors improve their skills
and provide more effective treatment for clients.
