Chapter 6
CLIENT FILE
MANAGEMENT
Oh Great Spirit, whose voice I hear in the winds, and whose breath gives life to all the world hear me. I come before you, one of your children. I am small and weak. I need your strength
and wisdom. Let me walk in beauty and make my eyes ever behold the red and purple sunset.
Make my hands respect the things you have made, my ears sharp to hear your voice. Make
me wise, so that I may know the things you have taught my people, the lesson you have
hidden in every leaf and rock. I seek strength not to be superior to my brothers, but to be able
to fight my greatest enemy, *MYSELF*. Make me ever ready to come to you, with clean hands
and straight eyes, so when life fades as a fading sunset, my spirit may come to you without
shame. Yellow Hawk, Sioux Chief
6. CLIENT FILE MANAGEMENT
6.1 Record keeping Practices
6.2 Individual or Group Case Notes
6.3 Initial Client Contact Form
6.4 Consent to Receive Client Services Form
6.5 Developing a Strength Based Wellness Plan for Clients
6.6 Strength Based Wellness Plan Template
6.7 Counselling Contract
6.8 Consent to Release Information Template
6.1 Record Keeping Practices
Record keeping practices are an important component of client care that ensures high
quality of user care. Record keeping provides client information, treatment plans, your
client’s response to treatment, serve as reminders as to your client’s status and provide
a source of communication of information to others concerned about your client. Client
records can be of assistance in legal matters and can be used for research, teaching,
audit or accreditation. It is important that records be accurate and objective. There are
four kinds of information required in a client file:
1. Identification information- initial visit information, Client Initial Intake Form, Consent
Form
2. Information relating to your client’s presenting problems- Strength Based Wellness
Plan
3. Information relating to Treatment- Counsellor- Client Assessment/Case Management,
progress notes, case management contacts, treatment plans, etc
4. Discharge information- discharge summary, follow up plans, relapse prevention
Each NNADAP office should have a system for recording information in their client’s
record that should be uniform throughout the organization.
Therefore, all record keeping practices should provide as complete and consistent
picture as possible of what happened from initial contact to termination of your client.
6.2 Individual or Group Case Notes
Case notes are the key to effective, comprehensive client record keeping practices.
Accurate and detailed case notes must be written and filed chronologically, as soon as
possible, after contact, and within 24 hours is good practice. Case notes form a critical
element of the client’s record of contact, intervention, treatment, relapse and aftercare.
Case notes form the basis for monitoring the ongoing assessment of the client’s
progress and the future service planning. Client cases notes need to be hard copied
(printed), signed and filed in the client’s file and any corrections must be initialed by the
party(s) involved. Client Case recordings are summaries of the client’s progress
towards their goals, their expected outcomes of each goal and information needed for
the reassessment in their wellness plan and ongoing treatment or community
involvement.
See appendix I for a blank Individual Case Note template which should contain
information about your client after each contact and with other parties involved in
the service delivery.
The following is an example of how to complete an individual case note.
CLIENT:
List only the client’s first name and their first initial of their last name
GUESTS:
List family members, youth, escort, or community involvement
STAFF:
Staff involved: list the staff who facilitated or is writing the case note first
and then all other staff present. Use staff first name and initial of last name
DATE:
February 18, 2010
TIME:
Example 09:30-10:45 hours or ( 75 minutes)
TYPE of CONTACT:
Record contact systematically:
-include all contacts, including telephone and written communication, with
clients, relatives, agencies, etc.
-also include unsuccessful attempts to contact your clients, appointments
missed or cancelled
Description of Event:
Write brief factual information
SOAP Note Format
The term “SOAP notes” refers to a particular format of recording
information regarding treatment procedures. Documentation of treatment is
an extremely important part of the treatment process. SOAP notes
consist of information presented in the following order:
Subjective:
This part of your notation should describe your objective impressions of the
client. For example: “Client DavidP was eager to complete the tasks presented to him today. Client
PeterW did not participate in his assessment. He chose to lay on the table with his head covered”
This section should be utilized to report subjective information of clinical
significance.
Describe the events in sequential order “ at 09:30 hours staff NoraB called… at
0940 hours staff NoraB received a visit from …
Provide detailed information about what and where statements were made
and by whom. At 1405 hours client PeterJ told staff NoraH to f…. off, he was not going to treatment.
Client Peter ran east on Lake Road at 1407 hours.”
Objective:
This section is where you will report the measurable and observable
information that you obtain during the treatment/lesson session. For
example: “Client BobA gave five examples of anger triggers for him at home.”
Remember that this section can be used to report behaviors that you
observe, not just the behaviors that you are targeting. For example, you
could report, “Client BillyB repeatedly (4 times) attempted to avoid talking with his Dad during his role play.
Client B stated that “he was not ready to confront his dad” (make direct quotes by clients to
back up behaviours observed)
Assessment:
This section is where you assess, in descriptive terms, the client’s
performance during the session and/or the session itself. For example:
“Client Billy’s performance showed a decrease in motivation over the last session. The introduction of new
activities requires additional explanation of …..”
A brief analysis of the data just collected, record your own and other
people’s thinking and/or conclusions in relation to information received.
“After meeting with Staff BrianJ who feels client BillyB is not able to meet with his dad using the direct approach
method, a new method of approach will be implemented to assist client BillyB.”
RECOMMENDATIONS:
Plan:
The final section of your SOAP notes is where you outline the course of
treatment, after considering the information you gathered during the
session. For example: “Group counselling work at the current level will be continued with a
modification of activities to provide for physical movement to facilitate sustained motivation and attention of
clients John and P.”
Plan: What goals are suggested by the analysis? What steps or tasks are
required to accomplish those goals? Who will take responsibility? When
do the tasks need to be completed? What is expected to be accomplished
by achieving the goal? (what is the intended outcome)
Note: All contacts produce data. Not all contacts result in assessment and
plans
Staff signature:
6.3 Initial Client Contact Form
The initial contact with client is a very integral component for beginning NNADAP
services with a potential client. It is important for the NNADAP worker to ensure that
each client’s cultural individuality, dignity, self worth and right to self determination is
respected and protected from the onset of their first visit. The Initial Client Contact
Form provides the first contact information about a client and their needs.
This form can be used by your agency (either the Intake worker, secretary or NNADAP
worker) when a client makes an inquiry for counselling/intervention services.
Reference to appendix J for a copy of the Initial Client Contact Form
6.4 Consent to Receive Client Services Form
This form can be used when a client agrees to participate in NNADAP services. The
Consent to Receive Client Services form is an important form in that you, the NNADAP
worker and potential client are entering into an agreement. When the client knows
from the onset of their visit; their commitment and your commitment as their worker both
will have clear obligations and commitment. This form will ease your client’s anxiety
around confidentiality and privacy as well as building rapport.
There are a few exceptions to the confidentiality obligations of counsellors. These
exceptions include:
• Cases in which there is reason to believe that a child (a person under the age of 19
years of age) needs protection under section 13 of the Child, Family and
Community Service Act (CFCSA)
• Cases in which individuals disclose their plans to harm themselves or others;
• having written permission from clients to speak to other professionals who are
involved with their family or to whom you are making a referral;
• Court orders to release documents or subpoenas to testify.
A sample of the Consent to Receive Client Services form can be found in
Appendix K.
6.5 Developing Strength Based Wellness Plan for Clients
Adults and children are often confronted with difficult life circumstances, traumatic
events, illness and losses that disrupt the flow of their life. It is during these times, they
may not even be clear about how to think or feel, about what is happening with them.
They are often struck by not being able to make sense of what happened. Their
relationship with themselves and others is affected. They may feel pain in their body
and develop other physical ailments. They recognize that something is not right.
It takes enormous courage to admit that something is not right in their world. Many
people try their hardest to not change and some never want to change. "Willingness to
try" is strength. You can acknowledge this strength in your client. As you begin to focus
on their strengths to deal with their life adversities and stress, and promote their
personal, social and academic development; as positive strengths rather than seeing
their deficits. You will find this to be a more helpful intervention process with every
client.
By focussing on the strengths and positive qualities of a client rather than seeing their
problems or them as a problem tends to be more helpful. When a client is an active
participant in his/her wellness plan versus a patient who is seen as too ill to know what's
best for him/her, your client is more apt to work towards their strength based case
wellness plan versus your plan.
By focussing on specific issues that need to be addressed rather than classifications
that help insurance companies or researchers to categorize people to study them and
determine what's best for a group of people but does not take into consideration your
client’s individual differences.
By assessing your client's strengths, thoughts, behaviours, situations, feelings, and
sensations that are the source of their difficulty and pain for them and working
collaboratively with input from your client (their family members and other professionals
if needed) the counsellor can develop a list of what issues and challenges need to be
addressed and the order in which they need to be addressed.
Individualized assessments can make specific issues apparent and a strength based
wellness plan can be set up in phases. This will guide your client to use the strengths
and resources they already possess to resolve the issues that brought them to their
community intervention.
Most ineffective behaviors or emotions are neither perfectly good nor bad. They played
a vital role at one point that may have been a protective factor. When your client’s
circumstance changes, they find that it is hard to let go of a habit even when it has no
purpose.
A Strength Based Wellness Plan involves looking at your client’s behaviors, thoughts,
emotions and systemic dynamics; seeing the strength in them and removing the parts
that no longer work.
Advantages to Strength-Based Wellness Plan
1. Leads to positively engagement of the client receiving services.
2. Identifies what is going well in the life of your client.
3. Develops the competencies that can establish positive expectations for your client.
4. Leads to a positive client-counsellor relationship
5. Helps to identify resources or services required for an intervention plan.
6. Empowers your client to take responsibility for their intervention outcomes
7. Documents the strengths or competencies that your client has completedi
The strength based wellness plan is a structured, goal-oriented schedule of services
developed jointly by your client and their wellness team. The plan must contain written
intervention-related goals and measurable objectives.
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Evaluate your client’s progress in meeting specified goals and objectives.
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Goals that are appropriate to the client’s age, culture, strengths, abilities,
preferences, and needs expressed by your client.
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Measurable objectives and target dates
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A list of the services to be provided.
•
The amount, frequency, and duration of each service for the duration of your
client’s treatment plan.
Steps of Individualized Strength Based Wellness Plan Development
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Step one: What are my client’s strengths and resiliency factors?
Step two: Intervention- Problem Selection
Step Three: Problem Definition
Step Four: Goal Development
Step Five: Objectives
Step Six: Intervention-Wellness Plan
Step Seven: Evaluation Plan = Adjustments or Results
Step 1: Client Strengths and Resiliency Factors
The Strength Based Wellness Plan should be based on the areas of your client
strengths and needs. These strengths are developed early in the counsellor-client
contact stage. The purpose of the plan is to provide both the counsellor and client with
clear information about the impact of their substance abuse, the protective/resiliency
factors and stressors (that exist in each individual client’s personal history and a plan for
recovery for each client.
The Resiliency factors that have protected your client are their connection to spirituality,
life purpose, family, friends, community and their nation connections too. The foundation
of an effective strength based wellness plan is the data gathered in a thorough
assessment or through the use of different, culturally appropriate evaluation tools. It is
important that the counselor is aware of their client’s current stressors, emotional status,
social network, physical health, coping skills, interpersonal conflicts, self-esteem and
other relevant factors in their client’s life. This information will:
• Guide the course of intervention for identified problems or issues.
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Provide documents that are updated to address your client’s current functioning
and needs
Here are some suggested client strength ideas.
Mental:
My best qualities are:
The best times I have had as a family are:
I am happiest when:
The most important thing I have ever done is:
My child’s/children’s life would really be better six months from now if:
My life would really be better six months from now if:
The things I like most about my child(ren) are:
Social:
Demonstrates a sense of humor
Smiles often
Is enthusiastic about life
Identifies personal strengths
Shows self-confident
Complies with rules
Trusts a significant person with his or her life
Talks about the positive aspects of life
Enjoys a hobby
Demonstrates age-appropriate hygiene skills
Emotional
Identifies own feelings
Expresses affection for others
Accepts the closeness and intimacy of others
Discusses problems with others
Shows concern for the feelings of others
Asks for help
Acknowledges painful feelings
Accept a hug
Resiliency Factors:
Spirituality
Identifies with a higher power
Attends or wants to reconnect with a spiritual group
Knows their clan, name
Connected to spirituality- knows life purpose (prosperity)
Participates in spiritual activities
Family
Expresses affection or a relation with family members
Identifies with family members
Socializes with family members
Interacts positively with siblings
Interacts positively with parents
Communicates about his/her behaviour at home
Maintains positive family relationships
Demonstrates a sense of belonging to family
Communicates with family
Family structure in place
has parent relationships
kind of parenting style
parents’ health and support outside the family relationships
knows family connections
has family support
Friends
Is popular with peers
Has friend relationships
Connected closely to friends
Requests support from peers and friends
Has friend support
Involved with friends
Community
Participates in community activities
Connected to a First Nation community
Has support within the community network
Involved in community activities
Nation
Involved in national relationships
Connected to nation
Has support within nation
Involved in nation’s activities
Step 2: Intervention Needs
Select with your client: their current stressors need, emotional need, social network
need, physical health need, coping skills need, interpersonal conflicts need, self-esteem
need and other relevant factors need
• Should be beneficial to your client.
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How is the problem evidenced in your client?
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How is the problem affecting your client’s overall functioning?
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What is your client’s perception of the problem
Step 3: Problem Identification
The client should attempt to identify their problem or issue that needs attention. The
counselor should remember that the mind can hurt or heal the body and the inner state
of one’s body can, in turn, heal or hurt the mind. Therefore in the intervention, we need
to pay attention to the
1) thoughts and feelings related to self, family and friends
2) one’s connection to a Higher Power
3) how self treats their body
4) what one sees as meaningful and purposeful in their life?
These factors are interwoven in determining one’s holistic strength based wellness.
The Strength Based Wellness Plan is a process conducted to ensure that intervention
goals, objectives, and services continue to be appropriate to your client’s needs and to
assess your client’s progress and continued need for services
Different therapeutic methods, both traditional and western such as sweats,
ceremonies, fasting, naming/clan, ceremonies, music, drumming, singing, cognitivebehavioral therapy, meditation, yoga, exercise- physical, mental, emotional, spiritual
reality therapy, solution-focused therapy, art therapy, laughter, play therapy, drama and
many other recommended lifestyle changes to address their physiological distress.
The counsellor then discusses what specific wellness pathway may work for their client
before and during the course of their intervention process. There should be flexibility
with the plan and your client’s evolving needs.
Step 4: Goal Development
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What is the broad goal for resolution of the problem?
Step 5: Objectives
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Each objective is a step toward the overall. Objectives should be specific,
measurable, attainable, realistic, and time-limited.
Step 6: Intervention- Wellness Plan
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The counselor’s role in assisting your client in accomplishing their objectives.
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The role of cultural competence is identifying culturally appropriate interventions.
Step 7: Evaluation Plan
The Strength Based Wellness Plan review is a process conducted to ensure that
intervention goals, objectives, and services continue to be appropriate to your
client’s needs and to assess your client’s progress and continued need for
services. The Strength Based Wellness Plan review requires the participation of
your client and their wellness team identified in your client’s Strength Based
Wellness Plan who are responsible for addressing the wellness needs of your
client.
Conclusion
We want to understand the client within the context of his/her home and community.
This assessment tool attempts to focus on the positive aspects which are consistent
with the culture of the client and attempts to define the needs of the mind, body,
emotions and spirit of individuals.
A Strength Based Wellness Template can be found in Appendix L. This template
can be used to develop a Strength Based Wellness Plan for your clients.
6.7 Counselling Contract
A counselling contract is an agreement that ensures your client’s right to make
decisions and have input into his/her counselling experiences- privacy, confidentiality,
commitment, safety, advocacy, ongoing support, etc. This form is an agreement
between you –the counsellor and your client, as to your client’s expectations from their
counsellor. A candid discussion about each topic should take place prior to counselling
session, so your client can be informed, trusting, honest and safe and you will have an
understanding of your client’s needs.
Some of the expectations that a client may have are:
 Keep all my client files in filing cabinets that are locked, whenever they are
not in use or unsupervised.
 Make sure that any documents identifying myself are stored out of sight when
meetings are held in program offices.
 Does not discuss my personal information or the work I am doing with others
in staff meetings.
 Obtain my consent before discussing my personal information with other
professionals or in case meetings.
 Select private locations for conversations with myself or my family members.
 Makes sure all unauthorized persons do not have access to the program
computers, e-mail, data, or files.
 Does not send confidential or personal information electronically without
proper security.
 In small communities where everyone is related to or knows everyone, uses
extra vigilance when needed to prevent breaches in confidentiality.
 Always protects the privacy of myself and my family.
 Provide structured sessions/ activities on a regular basis
 Provide written materials and other learning tools that pertain to my wellness
 Provide meeting facilities that are safe and comfortable
 To be available to discuss issues and concerns with myself and my family
 Provide information pertaining to my treatment progress to other agencies,
legal counsel, and courts when required
 To attend Court proceedings when necessary
 Provide feedback on the results of my assessments and progress in my
therapy
 Challenge and support me in my quest for personal growth and change in my
substance abuse issues.
A copy of the Counselling Contract is found in Appendix M.
6.8 Consent to Release Information Template
The Consent to Release Information Form is required to communicate with other
referral sources and/or destinations for all clients. All client specific information
collected during an interview is confidential and is not to be released without your
client’s written consent at any time for any reason. Exceptions are in cases when there
is suspected child abuse, when client records are subpoenaed by the courts or when a
doctor/psychiatrist requests information in a medical/psychiatric emergency.
When information is being shared among workers or agencies (treatment centre,
another agency/ counselor, court, etc), your client should sign an appropriate consent
form before this exchange taking place.
A sample of the Consent to Release Information Template is in Appendix N.
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Programs that practice the Strengths Perspective- School of Social Welfare - KU
School of Strengths Institute (28/02/11)