Session 14
Documentation & Record
Keeping
October 3-2012
Kim Bailey, BA, BSW, B,Ed, M.Ed. RSW
LEARNING OBJECTIVES:
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1. To know what constitutes a record
2. To understand the importance of
documentation & record keeping
3. To understand what information needs to be
documented
4. To understand the guidelines for
documentation & record keeping
5. To understand confidentiality
What is A Record ?
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RECORDS INFORMATION (Source: RIM – Using Records Centre
Services, 2006)(again, for our purposes, read "government" as
"board/school")
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A record is recorded information in any form created or received and
maintained by the government or under its control in the course of
government business.
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More specifically, the Archives & Records Act defines records as
including: books, documents, maps, drawings, photographs, letters,
vouchers, papers, and any other thing on which information is recorded or
stored by any means whether graphic, electronic, mechanical or otherwise.
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This definition includes information recorded on media other than paper,
such as video tape, film and sound recordings and all electronic
information.
3.9 Do Records Only Exist on
Paper?
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As the definition states, records can be in formats
other than paper. For example, if an e-mail requests
or documents a decision, initiates a process,
comments on a situation, documents a business
transaction, then consider those e-mails to be records.
Records can also be in the form of a photograph,
microfilm, video tape, and audio tapes. Documents
that are created using a spreadsheet, word processing
or presentation software, and/or data that is
maintained in a database are also considered to be
records.
3.8 Is Everything I Receive or Create
a Record?
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No, not everything will be a record. The following are not considered government records:
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Copies you keep regarding your employment such as performance appraisals
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An e-mail regarding lunch with a colleague
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Miscellaneous notices and memoranda such as "All Staff" emails, messages on upcoming special events,
or memos on minor administrative details
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Preliminary draft of letters, memos, reports, which do not form significant stages in the preparation of a
final document and do not record official decisions
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Duplicate copies of documents retained only for distribution or convenience
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Personal messages or simple phone messages
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Publications, catalogues, newsletters, periodicals are non-record unless you are the creator of the
publication
Blank forms and unsolicited advertising
Importance of Documentation
&
Record Keeping
Communication
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Documentation informs of the service provided, the
treatment and care plan, and the outcome of that care
as a continuous and contemporaneous record.
Documentation enables Spiritual Directors and other
professionals to use current, consistent data, and care
goals to facilitate continuity of care. Clear, complete,
accurate and factual
Documentation provides a reliable, permanent record
of client care and is an accurate record of the history
of the client’s care.
Accountability
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Documentation demonstrates the Spiritual Director’s
accountability and records their professional practice.
The Spiritual Director’s documentation may be used
in relation to performance management, internal
organizational inquiries and/or legal proceedings
(such as civil lawsuits or internal reviews)
Scope of practice,
Appropriate referrals to outside agencies .
Legislative Requirements
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Spiritual Directors are required to make and keep records of their
professional practice in accordance with standards of practice of their
profession and organizational policy and procedure.
OIIM Registration Booklet lists as some of the Basic Principles of
Trustworthiness to :
Maintain records for at least 2 years and no longer than 7 years after the
client no longer receives services.
Paper records are destroyed through shredding .
Electronic records are stored through a a system that allows permanent
deletion.
Records are expected to be kept , if in paper form, in a locked cabinet, and
if electronic, to be accessed only through a secure password protected
program. P. 14
Failure to keep and maintain certain documentation records as required,
falsifying documentation, incomplete or inaccurate documentation, signing
or issuing a document that the person knows or suspects to be false or
misleading, may be found to constitute unprofessional conduct by a
regulatory authority.
Quality Improvement
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Documentation may be used to evaluate professional
practice as performance reviews, audits and
accreditation processes, legislated inspections and
critical incident reviews.
Spiritual Directors can also use this information to
reflect on their practice and implement changes based
on evidence.
Documentation is evidence of the quality provision of
care and services to the public should it be called into
question.
Research
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Your records can identify trends and areas of
need that are worthy of professional research.
Quantitative versus Qualitative.
Example: Record documentation is a valuable
source of data for health researchers. It
provides information in relation to clinical
interventions, evaluates patient outcomes,
patient care and is a concise record, essential
for accurate research data and evidence based
practice.
Funding and Resource Management
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Data accessed from record documentation can
be used as an appropriate tool for lobbying and
advocating, can identify the type of care that
individuals require, the services provided and
the efficiency and effectiveness of care. Any of
these factors may impact on funding and
resource allocation. Accurate and
comprehensive documentation of interventions
provides a valuable source of evidence and
rationale for funding and resource
management.
GUIDELINES
DOCUMENTATION & RECORD KEEPING
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It is necessary to obtain informed consent from
a client before providing professional services
to the client.
Where possible clients should sign indicate
that they are agreeing to services. If a client is
illiterate or unable to sign their name- ensure
that it is documented that the client has
verbally agreed to services
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Keep case notes on a session-by-session
basis…use a consistent, simple format.
SAMPLE
Write case notes soon after each session.
If hand notes are written and then later entered
into a data base, the hand notes can be
destroyed (shredded)
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Record the date of each session, indicate the length of
each session.
Case notes should be signed in ink (blue or black ink)
and then the Spiritual Director’s name should be
printed and their designation added.
Notes are printed and placed in the files. When they
are printed, professionals sign their names and add
their professional designations to the entries they
have made wherever possible.
CONFIDENTIALITY
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Confidentiality is essential when providing
services
A Code of Ethics for Spiritual Directors
D) The Importance of Confidentiality
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Clients need to be informed at time of intake
about the limits to confidentiality. Prior to
releasing information to a third party, clients
are required to sign a release of information
form and this needs to be documented in the
client’s file.
Two Limits of Confidentiality
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The general expectation that Spiritual Director’s will keep information
confidential does not apply when disclosure is necessary to prevent serious,
foreseeable and imminent harm to a client or others. In all instances,
Spiritual Director’s disclose the least amount of confidential information
necessary to achieve the desired purpose. Spiritual Directors may break
confidentiality and communicate client information without permission
when required or permitted by relevant laws, court order
Spiritual Directors disclose confidential information with the informed
consent of the client or permission of the client’s legal representative and
demonstrate transparency with respect to limits to confidentiality that
applies to their professional practice by clearly communicating these
limitations to clients early in their relationship (Section 11 E of A Code for
Spiritual Directors).
Tips
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• ensure and maintain the confidentiality of the client
• develop and implement practices that protect confidentiality of information and data when
documenting in a record (including charts)
• records stored and archived confidentially
• confidentiality of electronic documentation and information
• systems and practices are in place that maximize the confidentiality of documentation and
records in diverse settings
• systems for sharing information with others ensures only relevant information with relevant
others (also required to maintain confidentiality)
• ensuring copies are used, managed stored and/or destroyed appropriately
• ensure copies are readable (including photocopies/faxes)
• client records are secure from unauthorized access, loss or theft during transfer, transmission
(i.e. electronic transfer) or transportation
• disposing of documentation (where appropriate to destroy) in a manner which maintains
confidentiality (e.g. confidential bins /shredding)
• those accessing (or seeking to access) documentation have the authority to access it.
• meets requirements for storage and disposal scheduling.
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In relation to electronic documentation systems, the following are important
• maintaining the confidentiality of passwords or any other access information
• changing a password as per the organization's policy or more frequently if security risk has
been identified
• using passwords that are not easily deciphered (e.g. date of birth that can be accessed in
personnel record)
• being aware and up to date on policies and procedures related to access to confidential
information
• fully logging off when not using the system or when leaving a terminal
• maintaining confidentiality of any hard copy information reproduced from the electronic
system
• protecting the confidentiality of information as it is displayed on monitors (including
consideration of the location and direction of monitors)
• never deleting information
• use of confidentiality statements and warnings on email transmissions (i.e. only to be read
by intended recipient)
• verifying that the information is legible and complete when receiving electronic
documentation
• ensuring the recipient has been informed so as to retrieve faxed documentation as soon as
possible2
Questions!?!?!?