Client Record Keeping Policy
Next Challenge will maintain individual client files. These have both a hard copy and electronic component. Hard copy files contain the client’s referral and case history information, signed confidentiality agreements and paper-based assessment forms and resources. Client files (hard copy and/or electronic records) include a record of delivered supports and services and include all communication related to the client even if the client was not present (e.g. emails to teachers, therapy planning meetings between therapists).
Client therapy notes
Client therapy progress notes and demographic information are stored in electronic form on PowerDiary. All clinical records will follow the SOAPIER or modified SOAPIER format. If a student is completing a progress note, a supervisor will review the note prior to completion. All Next Challenge clients have the right to request a copy of their therapy notes at any time.
Data storage & protection
All electronic files (including images of clients) are password protected and securely stored in the company system which comprises physical and encrypted online storage platforms. In a circumstance where an Employee is using a personal device for work related tasks, they will only store and access client information on the Next Challenge online platforms. If an Employee is required to download a document to a personal device, they will upload the document to a Next Challenge online storage platform and delete the file from their device. All devices and platforms used to store client information are password protected and passwords are updated on a regular basis. All hard copy files are stored in a locked filing cabinet.
Access
Client files (hard copy and electronic) will only be accessed by Next Challenge Management and relevant employees. Parent/s, legal guardians and clients over 18 years can access the information contained in their files by contacting Next Challenge, PO Box 141, Mount Hawthorn, Western Australia, 6915 in writing; by emailing [email protected]; or by calling Julie Hunt (NC Director) on (08) 9201 0707.
Audits
Client files (hard copy and electronic) will be audited annually according to the Next Challenge client file audit procedure.
Standards of record keeping
Next Challenge employees will maintain high standards of record keeping. Dated and signed records will be made in the electronic client file on every occasion of contact. Client reports are written as required and on request, and saved electronically. If more than one staff member is involved with a client, a combined report is the preferred method of report writing.
Retention of data & archiving
Next Challenge is working towards paperless data storage and archiving. Once a client has been discharged, client records will be kept (electronically archived) for 15 years after last contact (provided the client has attained 25 years of age). Complaint records are electronically stored in a locked folder on our online storage system and kept for 7 years from the date the record is made. Once this milestone is reached the client's file will be deleted and physical documentation shredded.
Date written: August 2006
Date Review Completed: October 2021
Due for Review: October 2023
Client therapy notes
Client therapy progress notes and demographic information are stored in electronic form on PowerDiary. All clinical records will follow the SOAPIER or modified SOAPIER format. If a student is completing a progress note, a supervisor will review the note prior to completion. All Next Challenge clients have the right to request a copy of their therapy notes at any time.
Data storage & protection
All electronic files (including images of clients) are password protected and securely stored in the company system which comprises physical and encrypted online storage platforms. In a circumstance where an Employee is using a personal device for work related tasks, they will only store and access client information on the Next Challenge online platforms. If an Employee is required to download a document to a personal device, they will upload the document to a Next Challenge online storage platform and delete the file from their device. All devices and platforms used to store client information are password protected and passwords are updated on a regular basis. All hard copy files are stored in a locked filing cabinet.
Access
Client files (hard copy and electronic) will only be accessed by Next Challenge Management and relevant employees. Parent/s, legal guardians and clients over 18 years can access the information contained in their files by contacting Next Challenge, PO Box 141, Mount Hawthorn, Western Australia, 6915 in writing; by emailing [email protected]; or by calling Julie Hunt (NC Director) on (08) 9201 0707.
Audits
Client files (hard copy and electronic) will be audited annually according to the Next Challenge client file audit procedure.
Standards of record keeping
Next Challenge employees will maintain high standards of record keeping. Dated and signed records will be made in the electronic client file on every occasion of contact. Client reports are written as required and on request, and saved electronically. If more than one staff member is involved with a client, a combined report is the preferred method of report writing.
Retention of data & archiving
Next Challenge is working towards paperless data storage and archiving. Once a client has been discharged, client records will be kept (electronically archived) for 15 years after last contact (provided the client has attained 25 years of age). Complaint records are electronically stored in a locked folder on our online storage system and kept for 7 years from the date the record is made. Once this milestone is reached the client's file will be deleted and physical documentation shredded.
Date written: August 2006
Date Review Completed: October 2021
Due for Review: October 2023
