Client Record Keeping Policy
Next Challenge will maintain integrated 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 therapy resources. Client progress notes and demographic information is stored in electronic note form on Google Drive. All hard copy files are stored in a locked filing cabinet and electronic files are password protected and securely stored in the company system.
Client files (hard copy and electronic) will only be accessed by Next Challenge Management and relevant employees.
Client files (hard copy and electronic) will be audited annually according to the client file audit procedure.
Next Challenge employees will maintain high standards of clinical record keeping. Dated and signed records will be made in the electronic client file on every occasion of contact. Full typed reports will be written as required. If more than one therapist is involved with a client, a combined report is the preferred method of report writing.
All records will follow the SOAPIER or modified SOAPIER format.
Once a client has been discharged, client records will be kept (archived) for 15 years after last contact (provided the client has attained 25 years of age).
Date written: August 2006
Date Review Completed: Feb 2017
Due for Review: Feb 2019
Client files (hard copy and electronic) will only be accessed by Next Challenge Management and relevant employees.
Client files (hard copy and electronic) will be audited annually according to the client file audit procedure.
Next Challenge employees will maintain high standards of clinical record keeping. Dated and signed records will be made in the electronic client file on every occasion of contact. Full typed reports will be written as required. If more than one therapist is involved with a client, a combined report is the preferred method of report writing.
All records will follow the SOAPIER or modified SOAPIER format.
Once a client has been discharged, client records will be kept (archived) for 15 years after last contact (provided the client has attained 25 years of age).
Date written: August 2006
Date Review Completed: Feb 2017
Due for Review: Feb 2019