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Documentation and Management
Documentation of work done with clients and stakeholders are an integral part of practice for community workers. Research has shown that record-keeping practices have an impact on client outcomes. Poor case notes can result in poor decision-making and adverse client outcomes (Preston-Shoot 2003, Cumming et al. 2007).
Psychologists create records for services that are under their control and responsibility. Psychologists maintain, store and dispose of records relating to their work in order to (SPS Code of Ethics, 2019):
Provide services in the future;
Allow for the replication of research;
Meet the requirements of organizations and institutions;
Ensure the accuracy of billing and payments;
Ensure compliance with the law;
Provide evidence in matters of disputes.
Responsibilities of the Psychologist in Making and Managing Documentation:
Psychologists ensure confidential records are safe. This involves:
The safe keeping of physical and digital information.
Records are kept minimally for three years, and longer if required for legal and organisational purposes.
Restricting disclosure to professional purposes with the client’s authorisation.
Psychologists ensure that clients are informed and aware of the limitations of the confidentiality of records.
In reporting to clients or sources of research funding, psychologists take reasonable steps to ensure the accurate reporting of:
Services provided (or the research conducted);
Fees, charges or payments;
Findings and the diagnosis.
What Information is Needed in a Case Note?
The guiding principle to decide what information is included in a case note is whether it is relevant to the service or support provided (Division of Clinical Psychology, British Psychological Society, 2013) .
This may include:
A range of biopsychosocial, environmental and systemic factors impacting the client. This includes consideration of an individual's culture, religion and spirituality;
Risk and resilience factors;
Facts, theory or research underpinning an assessment;
A record of all discussions and interactions with the client and persons/services involved in the provision of support including referral information, telephone and email correspondence;
A record of non-attendance, either by the worker or client, at scheduled and agreed meetings or activities.
Evidence that the worker and client have discussed their respective legal and ethical responsibilities, which may include:
Client rights, responsibilities and complaints processes;
The parameters of the service and support being offered and agreed to;
Issues relating to informed consent, information sharing, confidentiality and privacy;
Efforts to promote and support client self-determination and autonomy;
Professional boundaries and how dual relationships may be managed;
Record keeping and freedom of information;
Discharge planning;
Relevant legislative requirements and their possible implications for practice.
Details of reasons and any related actions or outcomes leading up to or following the termination or interruption of a service or support
Information recorded about a client should be impartial, accurate and complete, with care taken to ensure that:
Only details relevant to the provision of a support or service, which the client has consented to, are recorded;
When working with involuntary clients, only information relevant to statutory practice are recorded;
Notes are free from derogatory or emotive language;
Subjective opinions are qualified with relevant background information, theory or research;
Relevant information is not omitted;
When recording information about third-parties, such as information about a client’s relationship with significant others, it is equally important to separate fact from opinion.
PDPA Matters
(Taken from https://aic-mosaic.sg/2021/06/03/pdpa-community-care-organisation-professional-personal-data/)
With the enactment of the Personal Data Protection Act (PDPA), community professionals need to ensure that their documentation and records keeping are compliant with the standards of PDPA. Below are some key areas about the PDPA relevant to community professionals:
1. Getting Consent
When collecting any personal information from clients using a physical or electronic form, professionals will need to inform patients about the purpose of collecting this information. It is best practice to include a section in the form with a brief explanation of how the client’s data will be used. On websites, the declaration could be detailed on official Privacy Policy page.
The sharing of a client’s data can help healthcare and community care providers gain a holistic view of a client’s medical history and recommend the best rehabilitation programmes for their well-being. However, the organisation needs to disclose to client if any of the information collected would be shared with other public institutions.
2. Knowing Your Client's Rights
After collecting clients’ personal information, professionals should also allow them to have some degree of control over it. This includes giving them the option to withdraw consent and stop the organisation from collecting, using or disclosing their personal data at any time.
3. Data Security and Protection
Sensitive information such as a client's health records must be documented and managed securely. While some healthcare providers still keep physical records of their patients’ information, organisations are increasingly moving towards digitising those records to allow for seamless data-sharing across medical institutions. As you digitise the records, remember to implement measures to protect the clients’ data, such as using data encryption and data anonymity. Regardless of the format of data collected, a documentation system should be put in place to align data access protocols and standards of security so professionals can effectively manage the data access.
