| Function: |
Documenting |
| Policy: |
2-40 Client Files |
| CMHO Standard(s): |
M.E.2.1, M.E.2.2, M.E.2.3, M.E.3.1, M.H.2.1, M.H.2.2 |
| Approved: |
January 2009 |
2-40 CLIENT FILES
Approved January 2009
POLICY
All client files are the confidential property of St. Leonard’s Community Services and will be locked, protected from destruction, or unauthorized access.
Client confidentiality remains the over-riding principle in dealing with client files. St. Leonard’s Community Services staff will exercise due diligence for the retention of client-sensitive material in both paper and electronic format.
Client files will not be removed from the department’s property except under court order or when approved by the Service Director or delegate for medical and court appointments. When moving client files between locations, staff will exercise due diligence to ensure the security of the files.
PROCEDURE
Creation and Maintenance of Client Files
A numbered client file (electronic and paper) will be opened for all registered Agency clients.
Service Directors of each department are responsible for creating and maintaining electronic and/or paper client files. Paper copy client files will be organized as per the Order of Assembly (Refer to Documenting Appendix 1).
The client file serves as the record of the client’s involvement with the Agency and will contain:
- referral information,
- the presenting problem(s),
- client identifying information (demographic data),
- intake,
- assessment,
- case formulation
- treatment/action plans,
- case notes,
- weekly case management report and treatment/action plan review,
- discharge plans,
- aftercare/follow-up plans
(See Client Service Policy 10-40 Client Service Model).
Draft reports, letters, handwritten or rough notes will be shredded as soon as the final version of the document is completed. Copies in the client file will also be shredded.
Transporting Files
Prior to transporting a client’s file, i.e. for a medical appointment, the staff in charge of the shift and the staff transporting the file will review the file or parts of the file which are to be transported and record this information in the log book. Upon return, the staff in charge of the shift will document the return of the file in the log book and then will review the contents of the file in order to document in the log book whether or not the file contains all the information that was present before the file was removed from the department. For non-residential programs, when client files are removed from the premises, they will be signed out and in.
Closing Client Files
File closure consists of moving all paper copy information from the binder/file (active file) and placing it in a file folder in accordance with the Order of Assembly (Documenting Appendix 1).
Closed paper copy files are to be forwarded to the Manager/Supervisor within 30 days following service closure/discharge for final approval and closure. No paper copy client information is to be shredded until the discharge summary and the file have been reviewed by the Manager/Supervisor.
The Manager/Supervisor will also review the electronic client file to ensure it is accurate and complete.
Upon completion of the file review, the Manager/Supervisor will change the status of the electronic client file to closed and sign off and store the closed paper copy client file in a secure location. (See Documenting 2-60 Retention/Disposal of Client Files).
Audits
The Service Directors are responsible for conducting random electronic and paper file audits within their departments. A sampling of client files will be audited by the Executive Director as per the Quality Assurance policy (See Planning 1-10).
In order to ensure that client files contain current, accurate and complete information:
- On a bi-monthly basis, the Service Director will randomly select electronic and corresponding paper client files from each department to audit. The Service Director will document completion of the file audit by signing and dating the Client File Audit Checklist See Doc Appendix 2). The results of the audit will be shared with the appropriate departmental Manager or Supervisor and Counsellor (Primary Worker).
- On at least a quarterly basis, the Executive Director will have electronic and corresponding paper client files from each program randomly selected for submission to and audit by the Administration clerical staff. Staff conducting the audit will document completion of the file audit by signing and dating the Client File Audit Form. The results of the audit will be forwarded to the Executive Director for reporting to the Management Team. The Executive Director will maintain Client File Audit Forms and resulting reports for future reference.
Home
|
