RECORD KEEPING and NOTE TAKING for SCHOOL COUNSELLORS Lorna

RECORD KEEPING and NOTE TAKING for SCHOOL COUNSELLORS Lorna Martin (204) 945-7964 [email protected]

KEY 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?

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 Counsellin g Reports Teacher’s Mark book Counsellor ’s Case notes Clinician’s Case notes

CASE 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.

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 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 school leaving course change/timetable study skills test taking preparation scholarships Behaviour classroom returning from suspension attendance subject area concern post-secondary requirements social skills mediation Career making a career/educational choice CHOICES/Bridges/Career Cruising/inventory session resume writing portfolio Personal stress finances/money self-esteem gang sexuality friendship social/emotional health conflict resolution home relations peer pressure mental health weight housing Abuse harassment bullying physical emotional sexual verbal drug/alcohol/substance self Other: Additional information: Notes: see reverse side

GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING PERSONAL information CAN be shared under the following circumstances: GREEN With written consent LIGHT 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

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

GENERAL GUIDELINES FOR PROFESSIONAL INFORMATION SHARING (cont’d) GREEN Generally HEALTH information CAN be shared if the situation meets at least ONE of the following: 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 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) In the following circumstances obtain more information and/or get advice from a YELLOW supervisor, consultant or lawyer: LIGHT 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 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 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

The “Guidelines on the Retention and Disposition of School Division/ District Records” School boards must have a written policy concerning: 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.

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.

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.

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

CUMULATIVE FILE COMPONENT 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) 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) 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 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

SCHOOL COUNSELLING CASE FILES COMPONENT 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 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 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 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 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 [email protected] (204) 945-7964 or 1 800 282-8069, ext. 7964