6. Client File Management

Chapter 6 CLIENT FILE MANAGEMENT

Oh Great Spirit, whose voice I hear in the winds, and whose breath gives life to all the world - hear me. I come before you, one of your children. I am small and weak. I need your strength and wisdom. Let me walk in beauty and make my eyes ever behold the red and purple sunset. Make my hands respect the things you have made, my ears sharp to hear your voice. Make me wise, so that I may know the things you have taught my people, the lesson you have hidden in every leaf and rock. I seek strength not to be superior to my brothers, but to be able to fight my greatest enemy, *MYSELF*. Make me ever ready to come to you, with clean hands and straight eyes, so when life fades as a fading sunset, my spirit may come to you without shame. Yellow Hawk, Sioux Chief 6. CLIENT FILE MANAGEMENT

6.1 Record keeping Practices

6.2 Individual or Group Case Notes

6.3 Initial Client Contact Form

6.4 Consent to Receive Client Services Form

6.5 Developing a Strength Based Wellness Plan for Clients

6.6 Strength Based Wellness Plan Template

6.7 Counselling Contract

6.8 Consent to Release Information Template 6.1 Record Keeping Practices

Record keeping practices are an important component of client care that ensures high quality of user care. Record keeping provides client information, treatment plans, your client’s response to treatment, serve as reminders as to your client’s status and provide a source of communication of information to others concerned about your client. Client records can be of assistance in legal matters and can be used for research, teaching, audit or accreditation. It is important that records be accurate and objective. There are four kinds of information required in a client file: 1. Identification information- initial visit information, Client Initial Intake Form, Consent Form 2. Information relating to your client’s presenting problems- Strength Based Wellness Plan 3. Information relating to Treatment- Counsellor- Client Assessment/Case Management, progress notes, case management contacts, treatment plans, etc 4. Discharge information- discharge summary, follow up plans, relapse prevention

Each NNADAP office should have a system for recording information in their client’s record that should be uniform throughout the organization.

Therefore, all record keeping practices should provide as complete and consistent picture as possible of what happened from initial contact to termination of your client. 6.2 Individual or Group Case Notes

Case notes are the key to effective, comprehensive client record keeping practices. Accurate and detailed case notes must be written and filed chronologically, as soon as possible, after contact, and within 24 hours is good practice. Case notes form a critical element of the client’s record of contact, intervention, treatment, relapse and aftercare. Case notes form the basis for monitoring the ongoing assessment of the client’s progress and the future service planning. Client cases notes need to be hard copied (printed), signed and filed in the client’s file and any corrections must be initialed by the party(s) involved. Client Case recordings are summaries of the client’s progress towards their goals, their expected outcomes of each goal and information needed for the reassessment in their wellness plan and ongoing treatment or community involvement.

See appendix I for a blank Individual Case Note template which should contain information about your client after each contact and with other parties involved in the service delivery.

The following is an example of how to complete an individual case note. CLIENT: List only the client’s first name and their first initial of their last name GUESTS: List family members, youth, escort, or community involvement STAFF: Staff involved: list the staff who facilitated or is writing the case note first and then all other staff present. Use staff first name and initial of last name DATE: February 18, 2010 TIME: Example 09:30-10:45 hours or ( 75 minutes) TYPE of CONTACT: Record contact systematically: -include all contacts, including telephone and written communication, with clients, relatives, agencies, etc. -also include unsuccessful attempts to contact your clients, appointments missed or cancelled Description of Write brief factual information Event: SOAP Note Format

The term “SOAP notes” refers to a particular format of recording information regarding treatment procedures. Documentation of treatment is an extremely important part of the treatment process. SOAP notes consist of information presented in the following order:

Subjective: This part of your notation should describe your objective impressions of the client. For example: “Client DavidP was eager to complete the tasks presented to him today. Client PeterW did not participate in his assessment. He chose to lay on the table with his head covered”

This section should be utilized to report subjective information of clinical significance. Describe the events in sequential order “ at 09:30 hours staff NoraB called… at 0940 hours staff NoraB received a visit from …

Provide detailed information about what and where statements were made and by whom. At 1405 hours client PeterJ told staff NoraH to f…. off, he was not going to treatment. Client Peter ran east on Lake Road at 1407 hours.”

Objective: This section is where you will report the measurable and observable information that you obtain during the treatment/lesson session. For example: “Client BobA gave five examples of anger triggers for him at home.”

Remember that this section can be used to report behaviors that you observe, not just the behaviors that you are targeting. For example, you could report, “Client BillyB repeatedly (4 times) attempted to avoid talking with his Dad during his role play. Client B stated that “he was not ready to confront his dad” (make direct quotes by clients to back up behaviours observed)

Assessment:

This section is where you assess, in descriptive terms, the client’s performance during the session and/or the session itself. For example: “Client Billy’s performance showed a decrease in motivation over the last session. The introduction of new activities requires additional explanation of …..”

A brief analysis of the data just collected, record your own and other people’s thinking and/or conclusions in relation to information received. “After meeting with Staff BrianJ who feels client BillyB is not able to meet with his dad using the direct approach method, a new method of approach will be implemented to assist client BillyB.”

RECOMMENDATIONS Plan: : The final section of your SOAP notes is where you outline the course of treatment, after considering the information you gathered during the session. For example: “Group counselling work at the current level will be continued with a modification of activities to provide for physical movement to facilitate sustained motivation and attention of clients John and P.” Plan: What goals are suggested by the analysis? What steps or tasks are required to accomplish those goals? Who will take responsibility? When do the tasks need to be completed? What is expected to be accomplished by achieving the goal? (what is the intended outcome)

Note: All contacts produce data. Not all contacts result in assessment and plans

Staff signature:

6.3 Initial Client Contact Form

The initial contact with client is a very integral component for beginning NNADAP services with a potential client. It is important for the NNADAP worker to ensure that each client’s cultural individuality, dignity, self worth and right to self determination is respected and protected from the onset of their first visit. The Initial Client Contact Form provides the first contact information about a client and their needs.

This form can be used by your agency (either the Intake worker, secretary or NNADAP worker) when a client makes an inquiry for counselling/intervention services.

Reference to appendix J for a copy of the Initial Client Contact Form

6.4 Consent to Receive Client Services Form

This form can be used when a client agrees to participate in NNADAP services. The Consent to Receive Client Services form is an important form in that you, the NNADAP worker and potential client are entering into an agreement. When the client knows from the onset of their visit; their commitment and your commitment as their worker both will have clear obligations and commitment. This form will ease your client’s anxiety around confidentiality and privacy as well as building rapport. There are a few exceptions to the confidentiality obligations of counsellors. These exceptions include: • Cases in which there is reason to believe that a child (a person under the age of 19 years of age) needs protection under section 13 of the Child, Family and Community Service Act (CFCSA) • Cases in which individuals disclose their plans to harm themselves or others; • having written permission from clients to speak to other professionals who are involved with their family or to whom you are making a referral; • Court orders to release documents or subpoenas to testify.

A sample of the Consent to Receive Client Services form can be found in Appendix K. 6.5 Developing Strength Based Wellness Plan for Clients Adults and children are often confronted with difficult life circumstances, traumatic events, illness and losses that disrupt the flow of their life. It is during these times, they may not even be clear about how to think or feel, about what is happening with them. They are often struck by not being able to make sense of what happened. Their relationship with themselves and others is affected. They may feel pain in their body and develop other physical ailments. They recognize that something is not right. It takes enormous courage to admit that something is not right in their world. Many people try their hardest to not change and some never want to change. "Willingness to try" is strength. You can acknowledge this strength in your client. As you begin to focus on their strengths to deal with their life adversities and stress, and promote their personal, social and academic development; as positive strengths rather than seeing their deficits. You will find this to be a more helpful intervention process with every client. By focussing on the strengths and positive qualities of a client rather than seeing their problems or them as a problem tends to be more helpful. When a client is an active participant in his/her wellness plan versus a patient who is seen as too ill to know what's best for him/her, your client is more apt to work towards their strength based case wellness plan versus your plan. By focussing on specific issues that need to be addressed rather than classifications that help insurance companies or researchers to categorize people to study them and determine what's best for a group of people but does not take into consideration your client’s individual differences. By assessing your client's strengths, thoughts, behaviours, situations, feelings, and sensations that are the source of their difficulty and pain for them and working collaboratively with input from your client (their family members and other professionals if needed) the counsellor can develop a list of what issues and challenges need to be addressed and the order in which they need to be addressed. Individualized assessments can make specific issues apparent and a strength based wellness plan can be set up in phases. This will guide your client to use the strengths and resources they already possess to resolve the issues that brought them to their community intervention. Most ineffective behaviors or emotions are neither perfectly good nor bad. They played a vital role at one point that may have been a protective factor. When your client’s circumstance changes, they find that it is hard to let go of a habit even when it has no purpose. A Strength Based Wellness Plan involves looking at your client’s behaviors, thoughts, emotions and systemic dynamics; seeing the strength in them and removing the parts that no longer work. Advantages to Strength-Based Wellness Plan

1. Leads to positively engagement of the client receiving services. 2. Identifies what is going well in the life of your client. 3. Develops the competencies that can establish positive expectations for your client. 4. Leads to a positive client-counsellor relationship 5. Helps to identify resources or services required for an intervention plan. 6. Empowers your client to take responsibility for their intervention outcomes 7. Documents the strengths or competencies that your client has completedi

The strength based wellness plan is a structured, goal-oriented schedule of services developed jointly by your client and their wellness team. The plan must contain written intervention-related goals and measurable objectives.

• Evaluate your client’s progress in meeting specified goals and objectives.

• Goals that are appropriate to the client’s age, culture, strengths, abilities, preferences, and needs expressed by your client.

• Measurable objectives and target dates

• A list of the services to be provided.

• The amount, frequency, and duration of each service for the duration of your client’s treatment plan.

Steps of Individualized Strength Based Wellness Plan Development

 Step one: What are my client’s strengths and resiliency factors?

 Step two: Intervention- Problem Selection

 Step Three: Problem Definition

 Step Four: Goal Development

 Step Five: Objectives

 Step Six: Intervention-Wellness Plan

 Step Seven: Evaluation Plan = Adjustments or Results

Step 1: Client Strengths and Resiliency Factors The Strength Based Wellness Plan should be based on the areas of your client strengths and needs. These strengths are developed early in the counsellor-client contact stage. The purpose of the plan is to provide both the counsellor and client with clear information about the impact of their substance abuse, the protective/resiliency factors and stressors (that exist in each individual client’s personal history and a plan for recovery for each client. The Resiliency factors that have protected your client are their connection to spirituality, life purpose, family, friends, community and their nation connections too. The foundation of an effective strength based wellness plan is the data gathered in a thorough assessment or through the use of different, culturally appropriate evaluation tools. It is important that the counselor is aware of their client’s current stressors, emotional status, social network, physical health, coping skills, interpersonal conflicts, self-esteem and other relevant factors in their client’s life. This information will: • Guide the course of intervention for identified problems or issues.

• Provide documents that are updated to address your client’s current functioning and needs

Here are some suggested client strength ideas.

Mental: My best qualities are: The best times I have had as a family are: I am happiest when: The most important thing I have ever done is: My child’s/children’s life would really be better six months from now if: My life would really be better six months from now if: The things I like most about my child(ren) are:

Social: Demonstrates a sense of humor Smiles often Is enthusiastic about life Identifies personal strengths Shows self-confident Complies with rules Trusts a significant person with his or her life Talks about the positive aspects of life Enjoys a hobby Demonstrates age-appropriate hygiene skills

Emotional Identifies own feelings Expresses affection for others Accepts the closeness and intimacy of others Discusses problems with others Shows concern for the feelings of others Asks for help Acknowledges painful feelings Accept a hug Resiliency Factors:

Spirituality Identifies with a higher power Attends or wants to reconnect with a spiritual group Knows their clan, name Connected to spirituality- knows life purpose (prosperity) Participates in spiritual activities

Family Expresses affection or a relation with family members Identifies with family members Socializes with family members Interacts positively with siblings Interacts positively with parents Communicates about his/her behaviour at home Maintains positive family relationships Demonstrates a sense of belonging to family Communicates with family Family structure in place has parent relationships kind of parenting style parents’ health and support outside the family relationships knows family connections has family support

Friends Is popular with peers Has friend relationships Connected closely to friends Requests support from peers and friends Has friend support Involved with friends

Community Participates in community activities Connected to a First Nation community Has support within the community network Involved in community activities

Nation Involved in national relationships Connected to nation Has support within nation Involved in nation’s activities Step 2: Intervention Needs

Select with your client: their current stressors need, emotional need, social network need, physical health need, coping skills need, interpersonal conflicts need, self-esteem need and other relevant factors need • Should be beneficial to your client.

• How is the problem evidenced in your client?

• How is the problem affecting your client’s overall functioning?

• What is your client’s perception of the problem

Step 3: Problem Identification

The client should attempt to identify their problem or issue that needs attention. The counselor should remember that the mind can hurt or heal the body and the inner state of one’s body can, in turn, heal or hurt the mind. Therefore in the intervention, we need to pay attention to the 1) thoughts and feelings related to self, family and friends 2) one’s connection to a Higher Power 3) how self treats their body 4) what one sees as meaningful and purposeful in their life? These factors are interwoven in determining one’s holistic strength based wellness. The Strength Based Wellness Plan is a process conducted to ensure that intervention goals, objectives, and services continue to be appropriate to your client’s needs and to assess your client’s progress and continued need for services Different therapeutic methods, both traditional and western such as sweats, ceremonies, fasting, naming/clan, ceremonies, music, drumming, singing, cognitive- behavioral therapy, meditation, yoga, exercise- physical, mental, emotional, spiritual reality therapy, solution-focused therapy, art therapy, laughter, play therapy, drama and many other recommended lifestyle changes to address their physiological distress. The counsellor then discusses what specific wellness pathway may work for their client before and during the course of their intervention process. There should be flexibility with the plan and your client’s evolving needs.

Step 4: Goal Development

• What is the broad goal for resolution of the problem? Step 5: Objectives

• Each objective is a step toward the overall. Objectives should be specific, measurable, attainable, realistic, and time-limited.

Step 6: Intervention- Wellness Plan

• The counselor’s role in assisting your client in accomplishing their objectives.

• The role of cultural competence is identifying culturally appropriate interventions.

Step 7: Evaluation Plan

The Strength Based Wellness Plan review is a process conducted to ensure that intervention goals, objectives, and services continue to be appropriate to your client’s needs and to assess your client’s progress and continued need for services. The Strength Based Wellness Plan review requires the participation of your client and their wellness team identified in your client’s Strength Based Wellness Plan who are responsible for addressing the wellness needs of your client.

Conclusion

We want to understand the client within the context of his/her home and community. This assessment tool attempts to focus on the positive aspects which are consistent with the culture of the client and attempts to define the needs of the mind, body, emotions and spirit of individuals.

A Strength Based Wellness Template can be found in Appendix L. This template can be used to develop a Strength Based Wellness Plan for your clients.

6.7 Counselling Contract

A counselling contract is an agreement that ensures your client’s right to make decisions and have input into his/her counselling experiences- privacy, confidentiality, commitment, safety, advocacy, ongoing support, etc. This form is an agreement between you –the counsellor and your client, as to your client’s expectations from their counsellor. A candid discussion about each topic should take place prior to counselling session, so your client can be informed, trusting, honest and safe and you will have an understanding of your client’s needs.

Some of the expectations that a client may have are:  Keep all my client files in filing cabinets that are locked, whenever they are not in use or unsupervised.  Make sure that any documents identifying myself are stored out of sight when meetings are held in program offices.  Does not discuss my personal information or the work I am doing with others in staff meetings.  Obtain my consent before discussing my personal information with other professionals or in case meetings.  Select private locations for conversations with myself or my family members.  Makes sure all unauthorized persons do not have access to the program computers, e-mail, data, or files.  Does not send confidential or personal information electronically without proper security.  In small communities where everyone is related to or knows everyone, uses extra vigilance when needed to prevent breaches in confidentiality.  Always protects the privacy of myself and my family.  Provide structured sessions/ activities on a regular basis

 Provide written materials and other learning tools that pertain to my wellness

 Provide meeting facilities that are safe and comfortable

 To be available to discuss issues and concerns with myself and my family

 Provide information pertaining to my treatment progress to other agencies, legal counsel, and courts when required

 To attend Court proceedings when necessary

 Provide feedback on the results of my assessments and progress in my therapy  Challenge and support me in my quest for personal growth and change in my substance abuse issues.

A copy of the Counselling Contract is found in Appendix M. 6.8 Consent to Release Information Template

The Consent to Release Information Form is required to communicate with other referral sources and/or destinations for all clients. All client specific information collected during an interview is confidential and is not to be released without your client’s written consent at any time for any reason. Exceptions are in cases when there is suspected child abuse, when client records are subpoenaed by the courts or when a doctor/psychiatrist requests information in a medical/psychiatric emergency. When information is being shared among workers or agencies (treatment centre, another agency/ counselor, court, etc), your client should sign an appropriate consent form before this exchange taking place.

A sample of the Consent to Release Information Template is in Appendix N. i Programs that practice the Strengths Perspective- School of Social Welfare - KU School of Strengths Institute (28/02/11)