How should coaches manage record keeping

How should coaches manage record keeping

(Adapted from the British Psychological Society Guidelines. www.BPS.org)

There is an increasing public and governmental concern with the quality and the maintenance of competence in all fields of professional practice.

It is the responsibility of Coaches to ensure that they adopt a systematic and detailed method of record keeping. This can be achieved by ensuring continued competence and adhering to recognisable and acceptable standards of practice. In general it is good practice to consider that records are an aide memoire for the Coach. In addition, records provide evidence that due consideration has been given to the client and that the Practitioner is engaging in their professional responsibilities.

Coaching as an emerging and developing profession is increasingly considering professional self-regulation and development through lifelong learning. This is echoed by the demands of the private sector, educational and organizational settings. Since record keeping is central to good practice, the following suggestions have been proposed.

Equally the provision of therapy services is affected by government legislation such as The Health Act (1999), and as clinical governance becomes increasingly important and as therapy moves towards statutory regulation there is emphasis on local delivery of high quality health care through the public, private and third sector providers. Coaches can learn from this.

The Purpose of Record Keeping

• To improve continuity between sessions
• To provide a record for the use of the Coach, and in some cases, the client.
• To facilitate assessment, planning and evaluation of progress.
• Consideration needs to be given to the influence of different theoretical models in the process of record keeping, how this might affect coaching or therapy and the relationship with the client.
• To allow the collection of basic statistical information for the purposes of departmental audit where coaching or therapy is provided within an organizational context. This may include before and after outcome measures
• To provide a record that is clear, complete and up to date.

PROCESS vs. CASE NOTES

As far as the law is concerned there is no difference between record keeping and process notes or any other notes made by the Coach in connection with the client. Anything that identifies the client becomes part of the official record whether stored as part of the file or elsewhere (see Data Protection Act). There is no exemption under law to keep separate records for interpretation or speculation. It is therefore advised that process notes are made with the view that they may later be seen by the client or by others if part of a legal case.

There have been suggestions made in various organisations that notes should be kept in distinct sections: clinical information, supervision sessions on the client, personal and counter transference responses to client and own professional development. Whilst this may be appropriate for some coaches it has not yet been tested by law and so all notes made should be considered as part of the client record.

Practical Guidelines for Record Keeping

Current legislation does not prescribe whether or in what form records should be made. However recent legislation indicates that anything that refers to a client such as entry into a computer database, scribbled note in a personal diary indentifying the client by name or other means may be regarded as part of the Client Record for legal purposes.

The following guidelines reflect the general principles recommended by many professional organisations.

Each written record of contact with clients, their family, advocate or others is:

• Legible;
• Written in ink;
• Dated;
• Signed

Information should be:

• Concise;
• Relevant;
• Objective (non-judgmental).

Entries should be:

• Up to date (within 48 hours of a session);
• Reflect the coaching or therapeutic process;
• Signed after any alteration.

It is advisable that all written records made on a systematically identifiable record paper. This prevents disputes over authenticity. Since the introduction of the Access to Health Records Act (1990) it is considered good practice to keep records as if the client would read them.

You may choose to ensure your papers are clearly marked with

‘CONFIDENTIAL – NOT TO BE COPIED WITHOUT EXPRESS PERMISSION OF THE AUTHOR’.

Records kept in electronic form should follow the same guiding principles as those given for written records.

 

Video and Audio Recordings

In the case of videos and audio recordings of client sessions (for supervision or other purposes) prior informed consent must be obtained from the client. Issues of ownership, copying, security of recordings etc. should be discussed and clarified at the onset. The signed, written consent should be stored separately from the recording in order to preserve confidentiality.

Data Protection

For guidelines on the principles of the Data Protection Act and whether an individual Coach should register under the Act information may be obtained from the Information Commissioner, Wycliffe House, Water Lane, Wilmslow, Chesshire, SK9 5AF. Information Line: 01625 545 745. Website https://www.gov.uk/data-protection/the-data-protection-act. Useful documents from this site are Notification Exemptions – A Self Assessment Guide that has step-by-step questions to work through and Notification Handbook – A Complete Guide to Notification.

Any records made and kept are subject to data protection rules concerning:

• The nature of the data kept;
• Unauthorized access to data (security);
• Improper disclosure to third parties (confidentiality);
• Data subject rights (The Client’s right of access).

These rules are principally contained within the Data Protection Act 1998, which contains eight ‘data protection principles’, This Act supersedes the 1984 Act, and extends its cover to now include manual (i.e. paper records) as well as electronic records. The Act also creates a new category of ‘sensitive personal data’ that requires special consideration around disclosure. ‘sensitive personal data’ relates to information about racial and ethnic origin, political opinions, religious and other beliefs, trade union membership, offences committed or allegedly committed, details of proceedings for offences and information about physical or mental health and sexual life. Except as may be required by specific obligation (e.g. The Children’s Act 1989 and The Terrorism Act 2000) or as a result of the wider ‘duty of care’ to protect the client or another person from serious harm, data must not be shared with other unauthorised third parties. Expressly ‘sensitive personal data’ cannot, except for ‘medical purposes’ by ‘health professionals’ (or a person owing a duty of confidentiality equal to a heath professional), be shared with third parties without the explicit consent of the client.

It is, therefore, good practice to obtain informed written consent from the client if there is a possibility or intention to share any of the data held on them.

It should be noted that a court of law or other properly constituted court of enquiry with a power to take evidence has the power to subpoena paper records or any other data such as audio or visual recordings. Failure to comply with such a direction could amount to a contempt of court.

It is important to note that supervision records, whether case of process notes, may be considered part of a client record. For example a supervision session where John B is discussed and where this is recorded by the supervisor in any form may later be regarded in a court of law as part of the official record for John B. either John B himself, or someone with the legal right of access to records on John B may seek access to the relevant supervision record.

It is recommended that Coaches who are approached to release client records for legal purposes do not act until they have taken legal advice from their professional association representative.

Security of Records

All records should be kept securely locked, preferably in a fireproof cabinet or container within a secure area. There are no specific recommendations for the period of time to keep records. However, other organisations recommend that all records be kept for a period of six (plus one additional ‘safety’ year) after the last contact with the client. Different requirements may apply to records relating to children.

Paper records should be disposed of as carefully as they are stored. Records should be shredded or incinerated to ensure their destruction and illegibility.

It is the duty of the holder of any form of data to ensure that the data is kept securely so that unauthorized access and identification of the data subject do not occur. Data held on a computer (or in other electronic forms such as a personal organizer, personal digital assistant PDA) should be made secure from access by others either directly from the computer terminal, or from a modem, cable network or other means of access by the use of the secure passwords, data encryption, ‘firewalls’ or similar means of securing the site.

Those responsible for confidential information must ensure:

• That information is effectively protected against access by authorized third parties.
• The prevention of improper disclosure of information when stored, transmitted, received or in its disposal.

Access to Records

A person holding personal data on a client has a duty to inform them that such data is being collected and held, the purpose for which it will be used and provide them with details of how they can access the data. Except in certain cases such as ‘serious hard’ to the applicant or another person the holder (data controller/processor) must within 40 days give details of the ‘registerable data’ held.

The Data Protection Act (DPA) requires that held ‘personal data’ must be:

• Unless the rights of the subject can be adequately protected, not transferred outside the European Economic Area;
• Processed fairly and lawfully;
• Obtained only for one or more specific lawful purpose;
• Accurate and up to date;
• Not kept longer than necessary;
• Processed in accordance with the rights of the data subject;
• Protected against loss or unauthorized use;
• Relevant, accurate and not excessive for the purpose collected.

Other legislation concerning data access includes:

• Access to Health Records Act (1990) (part repealed by DPA (1998));
• Human Rights Act (1998);
• Freedom of Information Act (2000) (concerning public bodies and disclosure)

Records Following the Death of a Coach

Coaches are advised to make arrangement for their own sudden ill health or death so that the client’s confidential records are secure and left in the care of a responsible professional colleague. The Coach is advised to ensure that a qualified colleague is available to protect the interests of the client at this time.