RECORD KEEPING and
NOTE TAKING
for
SCHOOL COUNSELLORS
Lorna Martin
(204) 945-7964
lormartin@gov.mb.ca
KEY QUESTIONS
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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 PICTURE
Cumulative file
Pupil Support
file
Youth Criminal
Justice file
Counsellor’s
Caseload
Record
Teacher’s
Daily Record
IEP
Resource
Reports
BIP
Clinician
Reports
ITP
Counselling
Reports
Teacher’s
Mark book
Counsellor’s
Case notes
Clinician’s
Case notes
CASE NOTES – style and format
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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.
CASE NOTES – background
Include
 Client’s name
 Date
 Referral information (from, to)
 Interagency contacts and results
 Other contacts and results
 Signature of counsellor
CASE NOTES – content
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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
SAMPLE
CONFIDENTIAL COUNSELLING REFERRAL
Date: __________________________
Student Name: ___________________________________
STATUS:
 CRITICAL
 Urgent
 as soon as possible
Is the student aware of this referral?
 yes
 no
Referral by:
 self
 peer
name___________________________
 teacher
name___________________________
 administrator
name___________________________
 parent
name___________________________
 other
name___________________________
AREA OF CONCERN:
Academic
 school achievement
 course change/timetable
 test taking preparation
 school leaving
 study skills
 scholarships
Behaviour
 classroom
 returning from suspension
Career
 making a career/educational choice
 resume writing
 portfolio
Personal
 stress
 finances/money
 self-esteem
 gang
 sexuality
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friendship
health
home relations
mental health
housing
Abuse
 harassment
 physical
 sexual
 drug/alcohol/substance
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bullying
emotional
verbal
self
 attendance
 subject area concern
 post-secondary requirements
 social skills
 mediation
 CHOICES/Bridges/Career Cruising/inventory session
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social/emotional
conflict resolution
peer pressure
weight
Other: ______________________________________________________________
Additional information:________________________________________________
Notes: see reverse side
________________________________________________________________________________________________________________________________
GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
PERSONAL information CAN be shared under
the following circumstances:
GREEN
LIGHT
 With written consent
OR
 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 Act
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OR
Where organizations that are subject to FIPPA are
involved in a common program or integrated service
OR
GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
GREEN
LIGHT
PERSONAL information CAN be shared
under the following circumstances:
By Order of the Court
OR
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
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GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
GREEN
LIGHT
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Generally HEALTH information CAN be shared if the
situation meets at least ONE of the following:
 With written consent
OR
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
Act
OR
By Order of the Court
OR
To a person who is responsible for providing continuing treatment
and care to the individual (need not be a formal health services
provider)
GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
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In the following circumstances
obtain more information and/or
YELLOW
get advice from a supervisor,
LIGHT
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
GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
RED
LIGHT
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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
LEGISLATION
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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
issues relating to such
matters as...
The pupil file
 Access to pupil files
 Refusal of access to pupil files
 Types of information that may
or must be kept
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The “Guidelines on the Retention
and Disposition of School
Division/ District Records”
School boards must have a written
policy concerning:
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retention and destruction of records
security provisions
decision making re: access requests
The “Guidelines on the Retention
and Disposition of School
Division/ District Records” (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 FILES
Definition:
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 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.
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INFORMATION 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.
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PUPIL FILES
May be organized and separated
into sub-files by component
 Three components:
 cumulative file component
 pupil support file component
 youth justice file component
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CUMULATIVE FILE COMPONENT
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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
(cont’d)
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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
(cont’d)
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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
COMPONENT
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Exists for some students
Information about a student may
be held in more than one
location if a system of crossreferencing in place
Detailed documentation about
the provision of resource
services from within or outside
of the school division/district
PUPIL SUPPORT FILE
COMPONENT (cont’d)
Ongoing health/psycho-social /
counselling information
 School clinician reports /
correspondence / logs / notes
 Results of specialized
diagnostic tests
 Service provider reports
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SCHOOL COUNSELLING
CASE FILES COMPONENT
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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 RECORDS
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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/
SUSPICION OF ABUSE REPORTS
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Are NOT retained
At the school
 In the support file
 In the school counselling case files
 In the caseload records
because the report is based on an event or
suspicion that may be unfounded
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The report is stored securely and
confidentially with the school division
office as per division policy.
The information
comprising the pupil
support file and the
school counselling case
files should be secure
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 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 ACCESS
A 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 be
made for access to
records
Access may be
denied under
certain conditions
ACCESS 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
DISCUSSION
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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 INFORMATION
Contact:
Lorna Martin
lormartin@gov.mb.ca
(204) 945-7964
or
1 800 282-8069, ext. 7964