Recording Requirements/Guidelines
3-20
PROGRAMS AND SERVICES MANUAL
POLICY
RECORDING REQUIREMENTS/GUIDELINES
PURPOSE OF RECORD
The purpose of the clinical record is to:
- document the assessment and counselling process with clients;
- reflect recognized standards of practice;
- communicate effectively with internal staff and other professionals as required; and
- assist in summarizing, organizing and guiding the service delivery process.
OVERALL REQUIREMENTS
1. A new profile sheet is initiated for each new client in the AIDS Committee of Toronto (ACT) Client Services database.
2. A counselling log must be maintained for all active clients. Demographic information, presenting issues, and action taken must be entered.
3. Counselling notes should be written clearly and concisely, keeping in mind that the client, other staff, and other professionals outside the agency may read the record.
4. Counselling notes should be brief with supporting facts as needed. Impressions and opinions should be identified as such and kept to a minimum.
5. Each entry is to be dated.
