counseling report on students, Lecture notes of Career Counseling

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RECORD KEEPING andRECORD KEEPING and

NOTE TAKING NOTE TAKING

for for

SCHOOL COUNSELLORS SCHOOL COUNSELLORS

Lorna Martin Lorna Martin

lormartin@gov.mb.ca lormartin@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?

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 – background CASE NOTES – background

SAMPLESAMPLE 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  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

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GENERAL GUIDELINES FORGENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING PROFESSIONAL INFORMATION SHARING PERSONAL information CAN be shared under the following circumstances:  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  (^) Where organizations that are subject to FIPPA are involved in a common program or integrated service OR

GREEN

LIGHT

GENERAL GUIDELINES FORGENERAL 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 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)

GREEN

LIGHT

GENERAL GUIDELINES FORGENERAL 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

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 ofThe 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 RetentionThe “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.

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.