RECORD KEEPING and

NOTE TAKING
for
SCHOOL COUNSELLORS
Lorna Martin
(204) 945-7964
lormartin@gov.mb.ca
 KEY QUESTIONS
 What do I record?
 How much do I record?
 Where do I record?
 How long do I keep information?
 What information can I share?
 To whom can I share information?
 How do I decide what is confidential
and what is shareable?
 THE BIG PICTURE

Cumulative file Resource

IEP Reports
Clinician
BIP Reports
Pupil Support Counselling
ITP
file Reports

Counsellor’s
Youth Criminal Caseload
Record Clinician’s
Teacher’s Counsellor’s
Justice file Mark book Case notes
Case notes

Teacher’s
Daily Record
 CASE NOTES – style and format
 Write your notes with the expectation that
others will read them with a critical eye.
 Don’t alter the record after the fact. Strike
out the comment and replace it with
correction.
 Be as specific and precise as possible.
 Focus on objective, observable behaviours
and statements.
 Avoid jargon or diagnostic labels.
 CASE NOTES – background
Include
 Client’s name

 Date

 Referral information (from, to)

 Interagency contacts and results

 Other contacts and results

 Signature of counsellor
 CASE NOTES – content
 Presenting problem or concern
 Main points or main issues discussed
 Relevant information on interventions
 Long-term/short-term goals
 Indications of progress
 Plans/’homework’
 Actions taken
 Appendices (e.g., drawings, letters, tests)

THE RECORD SHOULD SHOW THAT REASONABLE,

ETHICAL STEPS HAVE BEEN TAKEN
SAMPLE
CONFIDENTIAL COUNSELLING REFERRAL
Date: __________________________
Student Name: ___________________________________
STATUS:  CRITICAL  Urgent  as soon as possible
Is the student aware of this referral?  yes  no
Referral by:  self
 peer name___________________________
 teacher name___________________________
 administrator name___________________________
 parent name___________________________
 other name___________________________

AREA OF CONCERN:
Academic
 school achievement  school leaving  attendance
 course change/timetable  study skills  subject area concern
 test taking preparation  scholarships  post-secondary requirements

Behaviour
 classroom  returning from suspension  social skills  mediation

Career
 making a career/educational choice  CHOICES/Bridges/Career Cruising/inventory session
 resume writing  portfolio

Personal
 stress  friendship  social/emotional
 finances/money  health  conflict resolution
 self-esteem  home relations  peer pressure
 gang  mental health  weight
 sexuality  housing

Abuse
 harassment  bullying
 physical  emotional
 sexual  verbal
 drug/alcohol/substance  self

Other: ______________________________________________________________
Additional information:________________________________________________
Notes: see reverse side
________________________________________________________________________________________________________________________________
 GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
PERSONAL information CAN be shared under
GREEN the following circumstances:
 With written consent
LIGHT
OR
 To avert or minimize imminent danger to the health or
safety of any person
OR
 To report a child who might need protection under the
Child Welfare Act
OR
 Where organizations that are subject to FIPPA are
involved in a common program or integrated service
OR
 GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)

GREEN
PERSONAL information CAN be shared
LIGHT under the following circumstances:

 By Order of the Court

OR
 As under the Youth Criminal Justice Act (Canada) to
facilitate the rehabilitation of a young person
OR
 To cooperate with a police and/or child welfare
investigation
 GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
GREEN Generally HEALTH information CAN be shared if the
LIGHT situation meets at least ONE of the following:
 With written consent

OR
 To avert or minimize imminent danger to the health or safety of any
person
OR
 To report a child who might need protection under the Child Welfare
Act
OR
 By Order of the Court
OR
 To a person who is responsible for providing continuing treatment
and care to the individual (need not be a formal health services
provider)
 GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
In the following circumstances
YELLOW
obtain more information and/or
LIGHT get advice from a supervisor,
consultant or lawyer:
 Consent is not provided or refused but there
may be a health or safety issue for any
individual or groups
 To report criminal activity to police (pursuant to
FIPPA)
 Where there is a demand or request to produce
information for a legal proceeding
 When a professional code of ethics may limit
disclosure
 GENERAL GUIDELINES FOR
PROFESSIONAL INFORMATION SHARING
(cont’d)
RED
LIGHT
Information can NEVER
be shared if there is:
 A legislative requirement barring
disclosure
 No consent and no need to know nor
overriding health/safety concerns
 Consent but no need to know nor
overriding health/safety concerns
 LEGISLATION
 The Public Schools Act (PSA)
 The Education Administration Act
(EAA)
 The Freedom of Information and
Protection of Privacy Act (FIPPA)
 The Personal Health Information Act
(PHIA)
 The Youth Criminal Justice Act (CJA)
 The Acts cover a range of
issues relating to such
matters as...
 The pupil file
 Access to pupil files

 Refusal of access to pupil files

 Types of information that may

or must be kept
The “Guidelines on the Retention
and Disposition of School
Division/ District Records”

School boards must have a written

policy concerning:

 retention and destruction of records

 security provisions
 decision making re: access requests
The “Guidelines on the Retention
and Disposition of School
Division/ District Records” (cont’d)
School boards must have a written
policy concerning:
 process and procedures for culling of

files
 procedures for confidential

destruction of information
 file transfer
Every school
division/district to
appoint an “Access
and Privacy” officer.
 PUPIL FILES
Definition:
A record or collection of records
respecting a pupil’s attendance,
academic achievement and other
related matters in the possession
or control of a school board.
(PSA 42.2)
 WHAT SCHOOLS DO
 The school is authorized to
collect information that relates
directly to what schools do.
 Schools provide educational

programs and services

supporting the pupil’s
educational progress.
INFORMATION COLLECTION
 Collect only as much
information as is needed for the
purpose for which it is collected
 When collecting directly from

the individual, the person must

be informed of the purpose and
authority for the collection and
the name of a contact person.
 PUPIL FILES
 May be organized and separated
into sub-files by component
 Three components:

 cumulative file component

 pupil support file component

 youth justice file component

CUMULATIVE FILE COMPONENT
 Standard or routine information
that schools have on all pupils
 Behavioural misconduct
information including
suspensions/expulsions
 Child custody, guardianship
agreements or orders
 Home/school communications
CUMULATIVE FILE COMPONENT
(cont’d)
 Cross-reference listing identifying the
location of all information about a pupil
that is held by the school division/district
 Results of tests administered to most
students
 Individualized Education Plan and/or
Health Care Plan, and/or Behavioural
Intervention Plan and/or Individualized
Transition Plan
CUMULATIVE FILE COMPONENT
(cont’d)
 Up-to-date notations or referrals
to/contacts with external agencies

 Admission advisement concerning

whether the student has used or is
continuing to use social service
psychological/psychiatric or
counselling resources
 PUPIL SUPPORT FILE
COMPONENT
 Exists for some students
 Information about a student may
be held in more than one location if
a system of cross-referencing in
place
 Detailed documentation about the
provision of resource services from
within or outside of the school
division/district
 PUPIL SUPPORT FILE
COMPONENT (cont’d)
 Ongoing health/psycho-
social / counselling information
 School clinician reports /

correspondence / logs / notes

 Results of specialized

diagnostic tests
 Service provider reports
 SCHOOL COUNSELLING
CASE FILES COMPONENT
 Exists for some students
 Often cross-references with clinical reports
 Ongoing counselling information (file not
required for one-time only counselling events)
 Indicates referrals and consultations
 Includes sufficient information to allow
monitoring and evaluation of services and
timelines by counsellor
 Includes relevant details to support student’s
needs
 CASELOAD RECORDS
 Considered equivalent to a teacher’s daily record
 Indicates daily activities (e.g., classroom
guidance sessions, career cruising, mediation for
single event, suspension transitioning)
 Shows planned events/sessions for upcoming
day/week/month
 Does NOT contain confidential information; may
contain names of counsellees that ought to be
shared only on a ‘need to know’ basis
 CHILD PROTECTION/
SUSPICION OF ABUSE REPORTS
 Are NOT retained
 At the school
 In the support file

 In the school counselling case files

 In the caseload records

because the report is based on an event or

suspicion that may be unfounded
The report is stored securely and
confidentially with the school division
office as per division policy.
 The information
comprising the pupil
support file and the
school counselling case
files should be secure
 All recorded information
about a pupil that is either
generated or received by
school division/district
staff is in the custody, or
under the control of the
school division/district
 ACCESS AND PRIVACY
 Parent, guardian, or pupil
 Staff access:

 To the extent that the

information is necessary
to assist in the
educational progress or
schooling of the pupil
 REFUSAL TO ACCESS
A school board may refuse to provide access to all
or part of a pupil file where disclosure could
reasonably be expected to:
 cause unreasonable invasion of privacy of a
third party;
 be detrimental to the education of the pupil;
 cause serious physical or emotional harm to
the pupil or another person; or
 be injurious to the enforcement of an
enactment or the conduct of an
investigation under an enactment
(PSA 42.3(2))
Application must be
made for access to
records
Access may be
denied under
certain conditions
 ACCESS AND PRIVACY

 Under the PSA, an employee

competent to interpret the
information in the file must
be made available to assist
any parent or pupil who has
been granted access to a
pupil file
 DISCUSSION
 Distinction between cumulative files, pupil
support files, criminal youth justice files,
clinical files, counselling files, caseload
records and resource teacher plans
 Access to files – PSA legislation vs FIPPA
legislation
 Sharing confidential information – ‘need to
know’ for personal programming and safety
 Your context
 FOR FURTHER INFORMATION

Contact:
Lorna Martin
lormartin@gov.mb.ca
(204) 945-7964
or
1 800 282-8069, ext. 7964