Record Keeping: Performance, Conduct & Ethics
Adapted from an article by Emma Pratt – October 27, 2016
In this digital age issues around record keeping are often a source of angst and sometimes confusion for coaches. Throw in the data protection and privacy laws that prevail in different geographies and guidance provided by professional bodies and it can be hard to see the wood for the trees.
This brief article attempts to lay down some working principles for record keeping and some strategies to help you apply them.
By way of a disclaimer, the principles outlined below are the opinion of the author and do not constitute legal advice. If you wish to get a formal legal opinion you should make contact with a lawyer specialising in Privacy & Data Protection in your legal jurisdiction.
Confidential client information should:
- Be stored securely (whether offline or online). Many in this era of cyber-theft think about the possibility of being hacked but of equal concern could be paper records that are left on a desk overnight for the someone to read, records locked in a filing cabinet that are destroyed by floods or simply leaving your briefcase on the bus or train
- Only be shared if you are legally permitted to do and if it is in the client’s best interest
- Be retained for as long as it may usefully be required or for a period which is legally mandated. Many professions (and commissioners) require you to hold records for defined periods of time (such as 8 years) and in these scenarios this requirement takes precedence over the ICO (Information Commissioners Office) guidance which states that records should be held for no longer than is necessary.
Maintain Accurate Records
Your records should be a comprehensive, clear and accurate representation of the coaching that you provided. In essence, this means that records should be written so that anyone, including the client, can understand your notes without your input. Many who use profession-specific notation take exception to this interpretation but regardless of your viewpoint as the movement towards client engagement, transparency and note-sharing (with clients) advances it’s likely to mean that your notes will need to be readable by a non professional, most notably the person paying the bill.
They must also be completed as soon as possible after coaching has been provided. Obviously, this point is open to interpretation but having discussed it with many supervisors and practice owners the general consensus appears to be within 24 hours. If you disagree with this timeframe (and many do) consider a scenario where you see several clients per day and you write up your notes 2 days after you’ve seen a client. Then imagine being cross-examined by a prosecution lawyer in a criminal negligence case about your ability to recall the exact details of one consultation amongst 16-20 un-recorded consultations.
Whilst you may not view this as a conventional “record keeping” activity most coaches are required to maintain and develop their knowledge and skills. With this in mind, it makes sense to keep a full and accurate log of when, what and how CPD (Continuing Professional Development) was undertaken.
You should maintain a record of the fact that your client has granted you the right to work with them.
Record Keeping Strategies
The following strategies assume the use of a practice management system of some sort rather than a paper-based record keeping system.
Your system should:
- Be password protected
- Encrypted in flight (as the information is transmitted over the internet)
- Be backed up daily (minimum) and to a separate physical location by the service provider
- Be capable of long-term retention and immediate deletion dependent upon circumstances
- Be capable of revoking access to users remotely
- Be capable of limiting access by user role so that users who don’t need to see sensitive information don’t get access to it
Your system should be capable of:
- Time/date stamping notes so that you have a definitive (unalterable) record of when the note or assessment was made.
- Locking down notes or assessments after a defined period of time so that they cannot be retrospectively amended
- Capturing text-based notes with appropriate tools to aid assessment, coaching and outcomes, including annotation tools, images etc
Your system should be capable of recording time spent on CPD as well as details about the activity that was undertaken. In addition, it is advantageous if the system can provide some sort of auditable list of the CPD activity that you have undertaken over a given period of time.
Your system should be capable of recording that consent has been granted along with a time/date stamp of when it was granted.