Taking Clinical Notes and Record Keeping Workshop - by Mia Logie
Maureen McEvoy is easy to love. She has a great sense of humour, relates well with the audience, and gets the important points across. She is succinct, which I greatly appreciate when spending six hours on a Saturday perfecting my clinical note-taking skills.
One of the reasons clinical note-taking is difficult is because we have to keep several perspectives in mind. The reason we take notes for our clients is to give them the best care. We do this by taking note of threads we would like to follow-up on in due time, and relevant details that help us remember particular information about the individual. We need to keep in mind what is called ‘Continuity of Care’ so that if something happens to us, another clinician can pick up where we left off with minimal impact on the client.
What complicates matters is that our notes can be called upon by certain authorities, including ICBC and the courts. Their notes about our client's mental well-being may not be in our client's best interest. One example is a client who has endured sexual violence. Exposing details from these events publicly may re-traumatize the client. As our job is NOT to clarify what happened, so to use them to support the process of understanding that may harm the client. Any notes we may have taken around event details may not line up with police reports. Most likely our client was in severe distress as we worked through their trauma with them.
In addition, our clients may request to see the notes we take. Some things we jot down may be hard to take when a person is vulnerable.
This means we have many different stakeholders that could have legal access to our notes, and keeping them all in mind for all the different situations relevant to our clients may be difficult!
Below you will find some bullet-points from the workshop:
- Documentation is key. At the initial session document that you did verbal consent, document how the client responded to questions around suicidal ideation if one parent is non-consenting and the reason this is acceptable in the specific case etc. Even if you document that you knew you had a dilemma when the clients shared XX, and then the steps you took (supervision).
- Context is key. Client in addictions recovery > document what triggered the relapse (‘family event’), and that this kind of relapse is typical for a client at this stage of recovery. This is an important context for the courts. Also minimizing abuse before going into courts > typical traumatic bonding.
- Develop your own shorthand.
- The age of consent for children is unclear: 12 for medical procedures. 14 is the presumed age for sexual consent, even if the books say 16. Under 12/14 both parents need to consent to counselling, even if only one needs to provide written consent.
- Privacy Commissioner (PPIA Protection of Personal Info Act by Province)
- If you counsel with parents/ kids, add to your consent form: I will not be able to comment on your parenting skills (unless I see you with your children and I witness actual parenting)
- If your notes are requested you do not legally have to provide them until a judge says so. You will have a veto response. If ICBC or a lawyer, ask if a summary of the notes a statement on a particular issue may suffice. You may need to provide an affidavit clarifying why the privacy of these notes is important.
- Provide a printed orientation letter at the first visit, to prevent a session from getting sucked up in going over all practice policies. Follow up on the next session to inquire if they have any questions.
- If your client brings sensitive information that could be relevant for police investigations, but the client is not ready to file a report, ask if the client is ok with you filing one where the client can remain anonymous.
- Make use of any counter-transferences that show up, and document the observations about the client here, and how you may want to follow-up in terms of your own processing/ training. E.g.: client inspired anxiety, or the client explained in detail what a Top Gun he is.
- If the possibility of suicidality occurs to you, you have to follow up and document (even when it seems far-fetched), to protect both yourself and the client.
- If you suspect a diagnosis but you do not have the mandate to diagnose, write down what you observe, then any trained clinician will know what that means.
- Details will never be admissible in court, deemed as hearsay, but can be used against the client to discredit by pointing out discrepancies
- You need to have a professional will that clarifies who will inherit your notes in case you pass away. This person ideally is a counsellor but doesn’t have to be, and can refer clients as suitable
- Maureen consults on cases e.g. if your notes are subpoenaed, and she supervises.
- Be consistent in how you go about things so that in the case you need to represent in court you can say what your typical process is, e.g. I take notes at the end of the day etc.
- If your clients email you personal details, explain why this makes you uncomfortable, that you will not respond and that you have to keep a printed copy with your files.
- Ransomware is a reality – counsellor's schedules and notes taken and withheld by cyber-pirates and not released unless a ransom is paid.
- Retention is generally seven years (children seven years after the age of majority, i.e. generally 16). This may change in the next couple of years though. When you think a client may be done for a while you can summarize your notes into a couple of pages. Consistency on how you do this is important, validate there is not a particular piece of info that you are trying to leave out.
- Do not keep separate notes, i.e. 'secret notes’. This can put you in a really difficult situation and makes both you and the client look bad.
- Many authorities will have the client sign a generalized consent, which includes access to counsellor notes. You do not have to provide notes automatically due to this consent.
- You can show up in court requesting a couple more days to allow time to consult a lawyer.
- A notice of motion (family/ civil court) is essentially the same as a subpoena (criminal court, etc.).
- Don’t go over your notes with a client that is court bound! This automatically denies you the right to resist sharing them. Anything that has been used to refresh the client’s memory is admissible.
- When a client requests notes, always ask first > Can I write a report? Can I talk to your new therapist? What do you need this for?
- If you end up sharing notes > ‘My therapist has explained to me some of her concerns around releasing vulnerable person info’
- Group notes: Who was there. What was the theme (e.g. psychoed)? What was the tenor of the discussion (e.g. validation, normalizing)? Relevant info about any particular members and if you are concerned about how you approached this. Conflict in the group, esp between members.