3. All clients using the Service will be asked
to sign a document to agree to notes
being kept. If a client will not sign, only
an initial appointment can be offered. In
this session it will be made clear why
counseling cannot be offered and other
options will be suggested.
4. Counseling notes may record
background information and key issues
worked on in the session.
These will vary in length and detail.
5. Under the Data Protection Act, clients have
a right of access to all notes kept on them.
If those notes contain references to other
individuals these may not be available to
the client, as protection is also granted to
third parties.
If the client wishes to see their file they
should ask their counselor, giving a week's
notice.
Details of case notes are exempt from
disclosure to third parties under Freedom of
Information legislation.
6. Provide high-quality service for client &
maintain continuity of care when a client is
transferred from one professional to
another.
Good record keeping protect the
counselor.
Clinical perspective- Provides a history that
a therapist can use in reviewing the course
of treatment.
Ethical perspective- assist practitioners in
providing quality care to their client.
7. Legal perspective- state/federal law
may require keeping a record & many
practitioners believe that accurate &
detailed clinical records can provide an
excellence defense against certain
malpractice claims.
Risk management perspective- keeping
adequate record is the standard of care.
–Accurate, Relevant & Timely
documentation useful as a risk
management strategy.
