Clinical Documentation and Paperwork

Document Number: COUNS--105pr
Revision #: 2.0
Document Owner: Dean of Students
Date Last Updated: 12/18/2017
Primary Author: Director of Counseling/Disability Services/Disability Services Center
Status: Approved
Date Originally Created: 02/17/2012
General Description

Description / Scope: Information about clinical documentation and paperwork relative to Counseling Center policy.

When Performed: As needed

Responsibilities: Counseling Services
Process Steps or Stages

1. Clinical Documentation and Paperwork

What happens:

A client file is generated for anyone who is seen for an intake interview for individual, couples, or group services. A record of information will be created for any student about whom any clinically significant information is received, either through direct contact or consultation.

When a student who is not already a client is seen or contacted for a crisis outside of the Center, the counselor will request certain identifying information, including the name and contact information of a close relative or friend should the client’s condition worsen, to follow up with the client after the crisis. Clinically significant information received about any student who has not sought services will be recorded and filed in the folder marked “Consultation” located in the client file cabinet.

1.1 Counseling Records

What happens:

The following information will become a part of the client’s counseling record:

1.1.1 Intake Records

What happens:

Whether seen as a walk-in or by appointment, the student seeking services is given the Client Questionnaire(Appendix D) prior to meeting with a counselor. A former client of the Center who is returning is given the Client Questionnaire Update (Appendix E) and Self-Report Form. An Intake Evaluation Form (Appendix F) should be completed by the counselor, as soon as possible, after the initial appointment and should be filed at the end of the day. The contact is marked on the Treatment Record (Appendix G) found in the chart. There may be times when it is necessary to schedule a student for an extended intake evaluation. When that occurs, the student should be scheduled in a timely manner for an appointment to complete the assessment.

1.1.2 Informed Consent and Confidentiality

What happens:

Confidential information may not be released or discussed with anyone, other than Center clinical staff without the written consent of the client, except in accordance with law. The Authorization for Release of Information (Appendix H) form must be signed and dated by the client for the form to be valid.

Requests for information from government agencies and attorneys or by court order or subpoena will be honored only upon advice of the University’s legal counsel and in accordance with the law. A signed consent must be obtained whenever confidential information is to be released to a person or agency outside the Counseling Center, including to Cumberland University staff and faculty, except in cases where the disclosure is required by law regardless of whether the client has signed a release.

The client’s counseling records are a separate entity from any other record on that student, and therefore is not part of his/her admission, academic, or disciplinary file. Similarly, any information gathered by the counselor will not be shared with any other department on or off campus without first obtaining a signed release from the client, with the exceptions noted on the Informed Consent and Confidentiality Form (Appendix B).

1.1.3 Client Request for Copy of Records

What happens:

The physical file, which includes all documentation pertaining to the client’s record, is considered property of the Counseling Center. Physical files are not to be taken from the Counseling Center. Upon written request, the file may be reviewed by the client in the presence of the primary counselor and/or director. In order to receive a copy of their file, the client signs a Receipt for Confidential Records form (Appendix I).

Although they do not have a right to the physical file, clients are entitled to inspect and receive a copy of their records upon written request. Under limited circumstances, a client’s request for a copy of records may be denied. Information such as test data is not accessible for copy because interpretation of such data must be made by a qualified professional. Clients do not have a right to any materials contained in the file that did not originate within the Counseling Center. In such cases, the client should contact the originating source of the specific records. Upon request, the Counseling Center will provide the client with the name of the originating source and the contact information of that source. If the counselor believes that access to files could be harmful to the client or a third party, access may be denied to portions or even the entire file.

1.1.4 Progress Notes and Phone or Miscellaneous Contact Notes

What happens:

Counselors record notes regarding the client’s progress in therapy following each session. These notes are to be charted as soon as possible after the appointment if not during the session.

Phone calls and other contacts with the client will be noted and recorded in the client’s chart. Contact with other parties regarding the client will be noted and recorded in the client’s chart.

1.1.5 Record Storage

What happens:

Client files are kept in the filing cabinet in the Director’s office. No student workers may have access to the client files so the confidentiality of fellow students who may be clients at the Center is not compromised. The filing cabinet will remain locked at all times, and only the counselor and the Supervisor will have a key.

Records will be destroyed in accordance with law no less than 7 years from last date of service. A record of client names and dates of service will be maintained in the Counseling Center upon destruction of client record.

1.1.6 Termination Summary

What happens:

Counselors will complete a Termination Summary form (Appendix J) when a client completes his or her course of therapy in the Counseling Center. Counselors record a diagnosis, a summary of interventions used, and the client’s progress toward therapeutic goals on this form. In certain cases, a client might fail to formally terminate therapy. In these cases, it is permissible for the counselor to complete the form at the end of the final semester in which services were provided to the client when Counseling Center statistics are being compiled.

COUNS--104pr_APPENDIX B CUCC Informed Consent and Confidentiality Form

COUNS--105pr_APPENDIX D CUCC Client Questionnaire

COUNS--105pr_APPENDIX E CUCC Client Questionnaire Update

COUNS--110pr_APPENDIX G CUCC Treatment Record

COUNS--105pr_APPENDIX H CUCC Authorization for Release of Information

COUNS--105pr_APPENDIX I CUCC Receipt of Confidential Record

Performance Metrics
Metrics: Compliance with standard policy and procedure
Subject Experts
The following may be consulted for additional information.
Director of Career Services and Internships
This document pertains to the following regulations:
University governance