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| Function: |
Documenting |
| Policy: |
Appendix 1 - Order of Assembly |
| CMHO Standard(s): |
M.E.3.2 |
| Approved: |
January 2009 |
Appendix 1 - ORDER OF ASSEMBLY – Client Files – Paper Version
Approved January 2009
To ensure consistency throughout the Agency, each component of the paper version of the client file is assembled in reverse chronological order, allowing staff to read the most recent information first.
Files may contain the following information organized under each of the Agency’s Client Service Model components.
- Referral
- Incoming Referral Form (source of referral, contact name of referral source, relationship of referral source to the client, referral date, referred to, contact name receiving referral and reason for referral),
- Outgoing Referral Form(s),
- Intra Agency Referral Form(s) (referral date, name of program making referral, name of contact making referral, referred to, program name, contact name receiving referral, reason for referral (previous program/treatment involvement if relevant to referral), consent to service signed, special needs, immediate risk factors),
- Referral Information Package i.e. Social History, Pre-sentence Report (if available at the time of referral),
- Pre-admission correspondence,
- Program Application Form.
- Intake
- Intake form (demographic information (name, age, parent/guardian/caregiver (if applicable), emergency contact, employment/education/legal status, medication, health/mental health information, client/family perception of problem, strengths/needs, previous treatment (if relevant), special needs (if not included with referral information), immediate risk factors (if not included with referral information), any other information gathered as part of reporting requirements (i.e. housing, income, etc.),
- Client Handbook Acknowledgement Form,
- Consent to Service Forms,
- Client Information Forms i.e. Probation Order,
- Participant Information Form,
- Parent/Guardian/Caregiver letter,
- Seven Day Visit form,
- Consent to Release and/or Consent to Obtain Information Forms,
- Service Agreement(s),
- Special Rate Agreement(s),
- Consent and Authorization for Admission,
- Client resume,
- Authorization of travel letter,
- RPAC Information – Notice of Placement, Recommendations, Notice of Discharge,
- Waiver of Liability for Injury,
- Waiver of Liability for Loss of Personal Property/Removal of Property.
- AIDS prevention information.
The following information may also be found in the Intake section of the client file:
- Linen inventory,
- Property sheet(s),
3. Legal
- Court documents,
- Bail undertakings,
- Family court documents,
- Curfew letters,
- Release certificates,
- Reintegration leaves,
- Critical information exchange,
- Warrants,
- Level of Detention Determinations,
- Court Disclosure document,
- Community Release Conditions,
- Probation Orders.
4. Medical
- Medical Information Sheet,
- Medical and Dental Contact Sheet,
- Medical Consent Forms,
- Consent and Authorization for Emergency Medical Treatment,
- Completed Medication Dispensing Record(s),
- Medical/Dental Initial Reports,
- Medical/Dental Annual Reports,
- Written Order (prescriptions).
- Assessment
- Assessment Report (may contain the following information, presenting problem/client’s perception of the problem, individual strengths, parent/guardian/caregiver needs and strengths, culture, mental health, risk behaviours, functioning (life domains), care intensity and organization, problem modifiers, legal history, education/employment, finances, family history/current living arrangements/life supports, leisure, culture/spirituality, problem solving capacity, previous treatment, case formulation, summary),
- Assessment tools, i.e. questionnaires, CANS score sheets, educational testing,
- Previous assessment reports (internal and external), social history, pre-sentence report (if available after admission), Psychological/Psychiatric Assessments,
- Clinical Consultation Note(s).
- Treatment/Action Plan
- Treatment/Action Plan (client name, date, completed by, period covered, domain, dimension, goal, planned outcomes, planned activities, resources, actual activities, actual outcomes, indicators, measurement method, signature page (client, Counsellor/Primary Worker, any other individuals involved with treatment/action plan),
- Safety contracts,
- Previous Treatment/Action Plans (Internal and/or External),
- Review of complaint procedure,
- Rights of clients in care.
- Progress Reports (if not contained elsewhere)
- Individual Programs,
- Educational Information (i.e. School Reports, report cards from community schools, correspondence from community schools, permission forms for school outings),
- Recreation/Leisure Information (documentation related to recreational activity i.e. bowling, baseball, etc.,
- Employment Information (work schedule, resume),
- Religious/Cultural/Spiritual Information.
- Case Notes/Individual Session Notes – Reviews and any revisions to Treatment/Action Plan, information about the client received from a doctor, teacher, parent, probation officer or CAS Worker, client behaviour issues, patterns and non-compliance, client disclosures (where it is not an allegation of abuse/maltreatment), observations about the client (positive or negative), reports on family visits, case conference/multidisciplinary team meeting details, employer/school contacts, any contacts made on behalf of the client, transition planning, aftercare planning.
Case Management Weekly Reports – Treatment/action plan progress, current situation, summary of behaviour interventions, summary and review of serious occurrence and incident reports, daily progress notes, strategies for upcoming week, any other significant or relevant information.
- Correspondence
- Any letters written on behalf of the client or received from third parties.
- Incident Reports and/or Serious Occurrences
- Evaluation
- Post-program/test questionnaires,
- Satisfaction Survey(s).
- Service Closure/Discharge
- Transition Plan,
- Discharge Summary,
- Discharge Plan (name, file number, discharging program, intake date, discharge date, reason for intake, team involved, services provided (what was helpful and what was no’t), areas of strength, treatment outcomes, treatment goals and strategies (how relevant persons are going to continue to assist the client), ongoing needs/areas to focus on following discharge, recommendations, information regarding options and methods for contacting Agency for future support).
- Aftercare/Follow-up
- Aftercare plan,
- Follow-up contact(s) (method, dates, frequency of contact).
- File Closure Form/Note
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