	Risk Prevention and Management

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

CA-RPM 7: Case Records*

Case records contain sufficient, accurate information to:

identify the consumer;
support decisions about interventions or services; and
document the delivery of services.

Interpretation: In addition to supporting the delivery of services, case records are an important risk management tool. Well-maintained records can help shield the organisation from allegations of misconduct and negligence, while poorly-maintained records and improper documentation are a known liability.

Independent contractors who provide direct services to organisation clients, maintain records for those clients in accord with CA-RPM 7.

Note: See CA-DV 17 for further guidance about the information to be included in case records for Domestic Violence Services (CA-DV).

Note: Please see Checklist: CA-Case Records in the Tools Index for additional assistance with this standard.

NA The organisation provides non-clinical group or crisis intervention services.

CA-RPM 7.01

The organisation maintains a case record for each person or family.

CA-RPM 7.02

Case records comply with all legal requirements and contain information necessary to provide services, including:

demographic and contact information;
the reason for requesting or being referred for services;
up-to-date assessments;
the service plan, including mutually developed goals and objectives;
copies of all signed consent forms;
a description of services provided directly or by referral;
routine documentation of ongoing services;
documentation of routine supervisory review;
discharge or aftercare plan;
recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and
a closing summary entered within 30 days of termination of service.

Interpretation: CA-RPM 7.02 describes the basic elements to be included in individual case records. COA recognises that in some cases not all listed information is obtainable for a person or family. In these cases, an explanation should be placed in the case record. The listed information may not be routinely available due to the nature of the service, e.g., a low demand shelter or drop-in centre.

CA-RPM 7.03

The case record contains essential legal and medical information, including, as applicable:

psychological, medical, toxicological, diagnostic, or other evaluations;
copies of all written orders for medications or special treatment procedures; and
court reports, documents of guardianship or legal custody, birth or marriage certificates, and any legal directives related to the service being provided.

NA The organisation does not obtain legal or medical information.

CA-RPM 7.04

Case record entries are made by authorized personnel only, and are:

specific, factual, relevant, and legible;
kept up to date from intake through case closing;
completed, signed, and dated by the person who provided the service; and
signed and dated by supervisors, where appropriate.

Interpretation: Case records and signatures can be paper, electronic, or a combination of paper and electronic.

CA-RPM 7.05

Progress notes comply with legal requirements, and are entered:

at least quarterly; or
monthly, or as required by law or regulation for individuals receiving protective services, out-of-home care, day treatment, or frequent or intensive counselling or treatment.

Update: Added Interpretation - 06/01/10

Added Interpretation

Interpretation: For credit counselling organisations providing DMPs, disbursement records can suffice as evidence of progress made.

CA-RPM 7.06

Service recipients may add a statement to their case records, and:

any response by personnel is added with the service recipient’s knowledge; and
the service recipient is given the opportunity to review and comment on such additions.

CA-RPM 7.07

At case closing, case records are reviewed and unsummarised notes, personal observations, and impressions are expunged.

Update: Added NA - 06/01/10

Added NA

NA The organisation only provides Financial Education and Counselling services.

QUICK JUMP TO


	PURPOSE: Comprehensive, systematic, and effective risk prevention and management practices reduce the organisation’s risk, loss, and liability exposure.

RELATED FILES


	PREVENTION Actions taken to minimise and/or eliminate social, psychological, or other conditions. Prevention can occur at the individual, group, community, and societal levels and enhances opportunities to achieve positive fulfilment.


	PRACTICE Established actions or ways of proceeding in the regular performance of organisational duties. Policies and procedures often guide practice.


	CASE RECORD A written compilation that describes the client and the services delivered. Records can be in hard copy and/or electronic format. The case record can be used as a source of information for quality improvement or other evaluation activities, for research purposes, or to demonstrate accountability to funding bodies.


	CONSUMER The individual, family, group, or community that seeks or receives services.


	SERVICE One or more organisation-operated programmes or activities that have a common general objective and deploy the organisation’s material and human resources in a planned and systematic manner. An organisation that publicly promotes or identifies itself in writing as offering a service, is licenced to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	RISK MANAGEMENT A systematic process of evaluating and reducing potential risks that may befall personnel, clients, an organisation, or a facility. Risk management activities are directed toward reducing an organisation’s legal and financial exposure, especially to lawsuits.


	INDEPENDENT CONTRACTOR An independently employed individual who contracts with an organisation to do a piece of work according to his/her own methods and is subject to an employer’s control only as to end product or final result of the work, not as to the means whereby it is to be accomplished.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	CRISIS INTERVENTION The immediate response to the acute needs of a person in crisis including referral to appropriate community resources, advocacy, support, or direct assistance.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialisation, income support, long-term care, and other care giving are among the functions of family life. The definition of “family” will rest with an individual’s indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, or significant others. Organisations that believe family is the central constellation in a child’s life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of “family.”


	MANAGEMENT See ADMINISTRATION


	LIABILITY An obligation, responsibility, or debt.


	CLIENT See SERVICE RECIPIENT


	ASSESSMENT An evaluation, which utilises professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of programme planning and service development for the organisation as a whole. See also DIAGNOSIS.


	SERVICE PLAN A written plan of action based on the assessment of consumer needs and strengths that identifies problems, sets goals, and describes a strategy for achieving those goals and engaging in joint problem solving with the consumer. Also known as a “treatment plan”.


	OBJECTIVE A sub-goal stated in operational terms, i.e., a statement that makes clear what expected results are to be measured or assessed.


	AFTERCARE Additional services provided beyond the period of primary care that offer continuity and supportive follow-up.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organisation for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child’s family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	EVALUATION The review and assessment of organisational operations, programmes and services.


	MEDICATION A prescribed or over-the-counter drug that is injected, taken orally, applied topically, or otherwise administered.


	SPECIAL TREATMENT PROCEDURES Any procedure that interferes with the right of a consumer to self-determination, involves risks about which a consumer should be informed, involves physical or psychological pain, or has the potential for harm. Examples may include, but are not limited to: interventions with consumers who resist treatment for drug or alcohol problems, wilderness/recreational activities that challenge physical abilities and contain inherent risks, or unusual approaches to behaviour management, the use of physical restraint, and the use of psychotropic medication. This term is synonymously used with HIGH-RISK TREATMENT.


	CUSTODY The care, control, and maintenance of a child. The court legally can award custody to an agency in abuse and neglect cases or to parents in divorce, separation, or adoption proceedings. Child welfare departments retain legal custody and control of major decisions for a child in foster care; foster parents do not have legal custody of the children for which they provide care.


	PERSONNEL The body of employees and/or volunteers that carries out the organisation’s tasks under the organisation’s administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards.


	INTAKE The client’s entry point for services at which eligibility is assessed against established criteria and a preliminary evaluation of the presenting problem occurs.


	CASE CLOSING A voluntary or involuntary process which occurs when an organisation no longer assumes responsibility for providing services to a particular individual, group, or family. Also known as “termination” or “discharge.”


	OUT-OF-HOME CARE Services for persons living in environments outside of their usual households. Foster Care Services are considered to serve persons in out-of-home care.


	SERVICE RECIPIENT The individuals, groups, organisations, or communities that use, receive, or benefit from programmes and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organisations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.