This document provides guidance to school counsellors on record keeping and note taking. It discusses what information to record, how much to record, where to record it, and how long to keep it. It also addresses how to decide what is confidential versus shareable, and to whom information can be shared. The document outlines different types of files like cumulative files and counselling case files. It provides guidance on case note style, content, and sharing information according to legislation.

1. RECORD KEEPING and
NOTE TAKING
for
SCHOOL COUNSELLORS
Lorna Martin
(204) 945-7964
lormartin@gov.mb.ca

2. 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?

3. THE BIG PICTURE
Cumulative file
Pupil Support
file
Youth Criminal
Justice file
IEP
BIP
ITP
Resource
Reports
Clinician
Reports
Counselling
Reports
Counsellor’s
Case notes
Clinician’s
Case notes
Counsellor’s
Caseload
Record Teacher’s
Mark book
Teacher’s
Daily Record

4. 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.

5. Include
 Client’s name
 Date
 Referral information (from, to)
 Interagency contacts and results
 Other contacts and results
 Signature of counsellor
CASE NOTES – background

6.  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
CASE NOTES – content

7. 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  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
________________________________________________________________________________________________________________________________

8. GENERAL GUIDELINES FOR
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

9. GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
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
GREEN
LIGHT

10. GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(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

11. GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(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

12. GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
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
RED
LIGHT

13. 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)

14. 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

15. 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

16. 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

17. Every school
division/district to
appoint an “Access
and Privacy” officer.

18. 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)

19. 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.

20. 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.

21. 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

22. 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

23. 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

24. 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

25. PUPIL SUPPORT FILE
COMPONENT
 Exists for some students
 Information about a student may
be held in more than one
location if a system of cross-
referencing in place
 Detailed documentation about
the provision of resource
services from within or outside
of the school division/district

26. 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

27. 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

28. 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

29. 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.

30. The information
comprising the pupil
support file and the
school counselling case
files should be secure

31. 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

32. 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

33. 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))

34. Application must be
made for access to
records
Access may be
denied under
certain conditions

35. 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

36. 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

37. FOR FURTHER INFORMATION
Contact:
Lorna Martin
lormartin@gov.mb.ca
(204) 945-7964
or
1 800 282-8069, ext. 7964