Communication

Question 1

Describe the difference between the Confidential Client File (practitioner notes) and the Client Service Record (client record)

Answer 1

CCF is the sensitive information about the client and may include psychological testing information. It identifies the client and documents the nature, delivery, progress, results, or recommendations of psychological services. It also includes appointment diary entries, working notes, assessment material, info stored on computer and sticky notes. The CSR forms an administrative component such as the dates and times of service, formal correspondence between 3rd parties and account information.

Question 2

All records, particularly the Confidential Client File serve 2 purposes. What are they?

Answer 2

To provide a service.To provide a record of legal accountability.

Question 3

What is a simple test of adequacy in note taking/record keeping?

Answer 3

Whether someone could pick up the file and continue service delivery.

Question 4

Which notes have the greatest weight in court?

Answer 4

Handwritten notes.

Question 5

What are the 2 key considerations regarding electronic/digital files?

Answer 5

Adequate safeguards to prevent access by others.Backup copies to prevent accidental loss of information.