2-50 CASE NOTES
Approved January 2009
 
POLICY

The Agency maintains accurate and current case notes on each client in the Client Services Manager database (CSM-DB) and/or paper copy in the client’s file.  Case notes are to be documented in a clear, easily understood manner and without jargon.

(Refer to Documenting Policy 2-40 Client Files)

PROCEDURE

The Counsellor (Primary Worker) will ensure that all significant contacts, (e.g. case conference, telephone call, etc.) observations with, about or on behalf of a client/family are documented in a case note that at a minimum includes the following information:

Case notes regarding individual counselling sessions with the client may include at a minimum the following information:

Case notes will be completed within 24 hours of the contact.

The Counsellor (Primary Worker) will shred the rough notes, once they are typed in the client’s file in the Client Services Manager database and/or inserted into the paper copy client file.

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