Session 14 Documentation & Record Keeping October Kim Bailey, BA, BSW, B,Ed, M.Ed. RSW

LEARNING OBJECTIVES: 1. To know what constitutes a record 2. To understand the importance of documentation & record keeping 3. To understand what information needs to be documented 4. To understand the guidelines for documentation & record keeping 5. To understand confidentiality

What is A Record ?

RECORDS INFORMATION (Source: RIM – Using Records Centre Services, 2006)(again, for our purposes, read "government" as "board/school") A record is recorded information in any form created or received and maintained by the government or under its control in the course of government business. More specifically, the Archives & Records Act defines records as including: books, documents, maps, drawings, photographs, letters, vouchers, papers, and any other thing on which information is recorded or stored by any means whether graphic, electronic, mechanical or otherwise. This definition includes information recorded on media other than paper, such as video tape, film and sound recordings and all electronic information.

3.9 Do Records Only Exist on Paper? As the definition states, records can be in formats other than paper. For example, if an requests or documents a decision, initiates a process, comments on a situation, documents a business transaction, then consider those s to be records. Records can also be in the form of a photograph, microfilm, video tape, and audio tapes. Documents that are created using a spreadsheet, word processing or presentation software, and/or data that is maintained in a database are also considered to be records.

3.8 Is Everything I Receive or Create a Record? No, not everything will be a record. The following are not considered government records: Copies you keep regarding your employment such as performance appraisals An regarding lunch with a colleague Miscellaneous notices and memoranda such as "All Staff" s, messages on upcoming special events, or memos on minor administrative details Preliminary draft of letters, memos, reports, which do not form significant stages in the preparation of a final document and do not record official decisions Duplicate copies of documents retained only for distribution or convenience Personal messages or simple phone messages Publications, catalogues, newsletters, periodicals are non-record unless you are the creator of the publication Blank forms and unsolicited advertising

Importance of Documentation & Record Keeping

Communication Documentation informs of the service provided, the treatment and care plan, and the outcome of that care as a continuous and contemporaneous record. Documentation enables Spiritual Directors and other professionals to use current, consistent data, and care goals to facilitate continuity of care. Clear, complete, accurate and factual Documentation provides a reliable, permanent record of client care and is an accurate record of the history of the client’s care.

Accountability Documentation demonstrates the Spiritual Director’s accountability and records their professional practice. The Spiritual Director’s documentation may be used in relation to performance management, internal organizational inquiries and/or legal proceedings (such as civil lawsuits or internal reviews) Scope of practice, Appropriate referrals to outside agencies.

Legislative Requirements Spiritual Directors are required to make and keep records of their professional practice in accordance with standards of practice of their profession and organizational policy and procedure. OIIM Registration Booklet lists as some of the Basic Principles of Trustworthiness to : Maintain records for at least 2 years and no longer than 7 years after the client no longer receives services. Paper records are destroyed through shredding. Electronic records are stored through a a system that allows permanent deletion. Records are expected to be kept, if in paper form, in a locked cabinet, and if electronic, to be accessed only through a secure password protected program. P. 14 Failure to keep and maintain certain documentation records as required, falsifying documentation, incomplete or inaccurate documentation, signing or issuing a document that the person knows or suspects to be false or misleading, may be found to constitute unprofessional conduct by a regulatory authority.

Quality Improvement Documentation may be used to evaluate professional practice as performance reviews, audits and accreditation processes, legislated inspections and critical incident reviews. Spiritual Directors can also use this information to reflect on their practice and implement changes based on evidence. Documentation is evidence of the quality provision of care and services to the public should it be called into question.

Research Your records can identify trends and areas of need that are worthy of professional research. Quantitative versus Qualitative. Example: Record documentation is a valuable source of data for health researchers. It provides information in relation to clinical interventions, evaluates patient outcomes, patient care and is a concise record, essential for accurate research data and evidence based practice.

Funding and Resource Management Data accessed from record documentation can be used as an appropriate tool for lobbying and advocating, can identify the type of care that individuals require, the services provided and the efficiency and effectiveness of care. Any of these factors may impact on funding and resource allocation. Accurate and comprehensive documentation of interventions provides a valuable source of evidence and rationale for funding and resource management.

GUIDELINES DOCUMENTATION & RECORD KEEPING It is necessary to obtain informed consent from a client before providing professional services to the client. Where possible clients should sign indicate that they are agreeing to services. If a client is illiterate or unable to sign their name- ensure that it is documented that the client has verbally agreed to services

Keep case notes on a session-by-session basis…use a consistent, simple format. SAMPLE Write case notes soon after each session. If hand notes are written and then later entered into a data base, the hand notes can be destroyed (shredded)

Record the date of each session, indicate the length of each session. Case notes should be signed in ink (blue or black ink) and then the Spiritual Director’s name should be printed and their designation added. Notes are printed and placed in the files. When they are printed, professionals sign their names and add their professional designations to the entries they have made wherever possible.

CONFIDENTIALITY

Confidentiality is essential when providing services A Code of Ethics for Spiritual Directors D) The Importance of Confidentiality

Clients need to be informed at time of intake about the limits to confidentiality. Prior to releasing information to a third party, clients are required to sign a release of information form and this needs to be documented in the client’s file.

Two Limits of Confidentiality The general expectation that Spiritual Director’s will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable and imminent harm to a client or others. In all instances, Spiritual Director’s disclose the least amount of confidential information necessary to achieve the desired purpose. Spiritual Directors may break confidentiality and communicate client information without permission when required or permitted by relevant laws, court order Spiritual Directors disclose confidential information with the informed consent of the client or permission of the client’s legal representative and demonstrate transparency with respect to limits to confidentiality that applies to their professional practice by clearly communicating these limitations to clients early in their relationship (Section 11 E of A Code for Spiritual Directors).

Tips ensure and maintain the confidentiality of the client develop and implement practices that protect confidentiality of information and data when documenting in a record (including charts) records stored and archived confidentially confidentiality of electronic documentation and information systems and practices are in place that maximize the confidentiality of documentation and records in diverse settings systems for sharing information with others ensures only relevant information with relevant others (also required to maintain confidentiality) ensuring copies are used, managed stored and/or destroyed appropriately ensure copies are readable (including photocopies/faxes) client records are secure from unauthorized access, loss or theft during transfer, transmission (i.e. electronic transfer) or transportation disposing of documentation (where appropriate to destroy) in a manner which maintains confidentiality (e.g. confidential bins /shredding) those accessing (or seeking to access) documentation have the authority to access it. meets requirements for storage and disposal scheduling.

In relation to electronic documentation systems, the following are important maintaining the confidentiality of passwords or any other access information changing a password as per the organization's policy or more frequently if security risk has been identified using passwords that are not easily deciphered (e.g. date of birth that can be accessed in personnel record) being aware and up to date on policies and procedures related to access to confidential information fully logging off when not using the system or when leaving a terminal maintaining confidentiality of any hard copy information reproduced from the electronic system protecting the confidentiality of information as it is displayed on monitors (including consideration of the location and direction of monitors) never deleting information use of confidentiality statements and warnings on transmissions (i.e. only to be read by intended recipient) verifying that the information is legible and complete when receiving electronic documentation ensuring the recipient has been informed so as to retrieve faxed documentation as soon as possible2

Questions!?!?!?