Documentation & Record-Keeping

Good records are key to good care and good business.

Comprehensive records create transparency, fulfill ethical and legal obligations, and protect you in complaints, lawsuits, and audits. While good records can’t prevent complaints from being filed, they demonstrate that you’ve acted in good faith and in the client’s best interests.

Developed in collaboration with the Ontario Association of Mental Health Professionals (OAMHP), this course includes:

• • The purpose of record keeping,

• The essential components of clinical records,
• How to meet the privacy requirements of PIPEDA,
• Handling access to and disclosure of records.

BCACC Members: $175.00+GST
Non-members: $220.00+GST

(scroll down to watch the introduction video from the course)

Good records capture – in real time – our observations, as well as our professional opinions and client related exchanges and events.

They allow us to plan the best possible clinical work with clients, and to help us reflect on professional practices and decisions.

Our records can:

• create evidence of our therapeutic process and procedural systems (such as billing and scheduling);
• support openness and transparency;
• help us protect ourselves from intentional or unintentional altered facts; and,
• ensure the clean and accurate transfer of information if the need arises for continuity of care.

Comprehensive and accurate records are important, because they help to create transparency, support us with ethical and legal obligations to human rights, and help us defend ourselves in cases of liable, lawsuits, or tax audit.  They are legal documents that may be accessed and used by different third parties and legal authorities.

Effective records put us in a good position to manage issues that might come up with clients and regulatory bodies. While good records cannot stop a complaint from being filed, they can demonstrate the ways we act in good faith and in the best interests of the client.